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

We decided that the Plan does not have to pay for the IV tubing extension set (S1015) and infection control supplies (S8301) provided on June 2, 2021.

You asked the Plan to pay for the medical equipment. You say that you would like these services reprocessed based on the medical records provided. The Plan denied your request. The Plan says these services as billed are not covered by Medicare or the Plan.

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 S1015 is IV tubing extension set. The CPT Code Manual definition of code S8301 is infection control supplies, not otherwise specified.

We find that CPT codes S1015 and S8301 are not eligible for payment per Medicare rules. Specifically, these codes have a status indicator of "I" under the Physician Fee Schedule which indicates that they are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the medical equipment have not been met. Therefore, we decided that the Plan does not have to pay for the IV tubing extension set (S1015) and infection control supplies (S8301) provided on June 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit (99212) provided on May 28, 2021.

You asked the Plan to pay for code 99212. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are 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. In this case, we have confirmed that code 99212 is a column II code to column I code 20206. 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 the office visit (99212) provided on May 28, 2021.
Appeal type: Drugs
Decision: Favorable

 We decided that the Plan has to pre-approve use of Keytruda.  You asked the Plan to pre-approve Keytruda. You say that the enrollee has metastatic advanced lung cancer and it would be detrimental to his health if he does not receive treatment. The Plan denied your request. The Plan says that the denial of authorization for this drug is correct, because studies have not proven that this drug is helpful for the enrollee.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Keytruda. Our reviewer says that the enrollee meets Medicare criteria for the requested use of Keytruda. Our physician reviewer found Keytruda is Food & Drug Administration (FDA) approved for the enrollee's condition. Given the enrollee's cancer is now metastatic and there has been no prior immunotherapy, combination therapy is reasonable. Keytruda is safe and effective and otherwise reasonable and necessary for the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Keytruda have been met. Therefore, we decided that the Plan has to pre-approve use of Keytruda.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the supplies provided on June 4, 2021.  You asked the Plan to pay for the services provided. You say that you provided the items at your own expense. The Plan denied your request. The Plan says the rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  We find that CPT code S8301 and S1015 are not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the supplies provided on June 4, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy services (S9338) provided on March 25, 2021 and March 26, 2021.  You asked the Plan to pay for code S9338. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  We looked at the file and Medicare rules. In this case, CPT code S9338 has a status code of "I" under the Medicare Physicians Fee Schedule Database (MPFSDB) and is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, this service. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services (S9338) provided on March 25, 2021 and March 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code 22869).

You asked the Plan to pre-approve the service. You say that the service is medically necessary. The Plan denied your request. The Plan says the Medicare criteria for reasonable and necessary are not met as this device has not been shown to be safe and effective in long term studies and there is a lack of evidence to support that interspinous spacer devices are as safe and effective as the gold standard of decompression. The Plan states the information submitted does not support that you meet the indications for this procedure as published by the manufacturer since imaging studies indicate severe stenosis.

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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy. 

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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex Superion device placement surgery (CPT code 22869).
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 does not meet criteria.  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 enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation.  The enrollee's 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 domiciliary or rest home visit (99334) provided on June 26, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for domiciliary or rest home visit. You say that these services were medically necessary and reasonable. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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. In addition, no medical records were provided to confirm if the services provided were urgent/emergent or medically necessary. 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 domiciliary or rest home visit (99334) provided on June 26, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Genvisc.

You asked the Plan to pre-approve Genvisc. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested drug does not meet step therapy criteria.

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 Genvisc. Our reviewer says that the documentation does not support that the requested drug meets step therapy criteria. Our physician reviewer found the enrollee has pain related to osteoarthritis of both knees, diagnosis confirmed with imaging studies. The enrollee has failed conservative treatment and prior treatment with Orthovisc. The documentation does not support that that the enrollee has tried and failed Monovisc. The documentation does not include an indication that Monovisc would likely be less effective and/or likely have adverse effects for the enrollee. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Genvisc have not been met. Therefore, we decided that the Plan does not have to pre-approve Genvisc.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for shoulder orthosis provided on July 6, 2021.

You asked the Plan to waive the coinsurance for the shoulder orthosis. You say that the provider sent incorrect insurance information. The Plan denied your request. The Plan says the correct coinsurance was applied.

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 durable medical equipment (DME), including shoulder orthosis. 

You have been asked to pay $12.27, which is 20% of the allowed amount for the shoulder orthosis ($61.36 allowed amount x 20% coinsurance = $12.27). The shoulder orthosis falls within the Durable Medical Equipment (DME) and Related Supplies 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 shoulder orthosis provided on July 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device provided on May 12, 2021.

You asked the Plan to pay for the services provided. You say that the equipment was used during the enrollee's surgery. The Plan denied your request. The Plan says payment would have been included under the facility claim.

The plan must follow Medicare rules. Medicare rules say that CMS does not pay any provider or supplier other than the facility for services furnished to a beneficiary. The file shows that a segmental gradient pressure appliance, and a pneumatic compression device were provided. 

We looked at the file and the rules. The facility must furnish all necessary covered services to the beneficiary either directly or under arrangements made with outside providers. The equipment was provided via arrangement of the facility. Payment for this service would have been included under the facility claim. Payment to you for this service is the responsibility of the facility. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device provided on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided on February 14, 2020, through February 21, 2020 and billed with diagnosis code I50.33.

You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration because the documentation supports diagnosis code I50.33. The Plan denied your request. The Plan says the documentation submitted does not support the diagnosis code billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with I50.33. 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 inpatient hospital services. Our reviewer says that the review has determined that the documentation did not support diagnosis code I50.33. Our physician reviewer found the reviewed documentation indicates that on presentation the history did not relate symptoms of chest pain, shortness of breath or paroxysmal nocturnal dyspnea. The physical exam did not demonstrate jugular venous pressure, rales on chest exam or peripheral edema. The enrollee demonstrated no prolonged oxygen desaturation. There was no brain or B-type natriuretic peptide obtained.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided on February 14, 2020, through February 21, 2020 and billed with diagnosis code I50.33.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar (CPT code 63047-AS-59) provided to the enrollee on March 19, 2021.

You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says this procedure is considered inclusive to CPT code 22630-AS, a single lumbar interspace arthrodesis using a posterior interbody technique, including laminectomy and/or discectomy to prepare interspace (other than for decompression); therefore, the code cannot be verified.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

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 service. Our reviewer found CPT code 63047 AS 59 - laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar billed to the health plan for services provided to the enrollee on March 19, 2021, does not meet criteria for billing or reimbursement consideration. The medical records indicate CPT 22630 AS was performed on March 19, 2021. CPT 63047 AS 59 is bundled with CPT 22630 AS. The medical records submitted does not include sufficient documentation to validate that 63047 AS 59 was performed as a distinct/ separate service, therefore no separate reimbursement is allowed.

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 service have not been met. Therefore, we decided that the Plan does not have to pay for laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; lumbar (CPT code 63047-AS-59) provided to the enrollee on March 19, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital service provided on November 22, 2020, through December 3, 2020 and billed with diagnosis related grouping (DRG) 073.  You asked the Plan to pay for the inpatient hospital services billed with DRG 073. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support DRG 073 with a diagnosis code of G93.41.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    In this case, you billed the inpatient services provided with diagnosis code G93.41. 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 inpatient hospital services billed with DRG 073. Our reviewer says that the review has determined that the documentation did not support DRG 073 with diagnosis code G93.41. Our physician reviewer found the review indicates that the enrollee presented to the emergency department with weakness after a period of unresponsiveness. In the emergency department she was alert and oriented. The progress notes during the hospitalization demonstrated no evidence of mental status changes. There was no documentation of encephalopathy during the admission.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital service provided on November 22, 2020, through December 3, 2020 and billed with diagnosis related grouping (DRG) 073.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral (CPT code 22511), for the enrollee.

You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says the wedge compression of the enrollee's L2 was more than twelve (12) weeks old.

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 service. Our physician reviewer found there is no documentation showing that this is an acute fracture that is less than three (3) months old. Criteria not met. 

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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve percutaneous vertebroplasty (bone biopsy included when performed), 1 vertebral body, unilateral or bilateral injection, inclusive of all imaging guidance; lumbosacral (CPT code 22511), for the enrollee.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing (81455) provided on May 29, 2021.  You asked the Plan to pay for code 81455. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  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. Medicare says that genetic testing submitted under code 81455 will be denied as not medically necessary as it is unlikely to impact therapeutic decision-making in the clinical management of the enrollee. Therefore, we decided that the Plan does not have to pay for the genetic testing (81455) provided on May 29, 2021.