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

 We decided that the Plan does not have to pay for the open treatment of clavicular fracture (23515) provided on December 11, 2020.  You asked the Plan to pay for the open treatment of a clavicular fracture. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 23515 is included in CPT code 23073.  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 23515 is open treatment of clavicular fracture, includes internal fixation, when performed.  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 open treatment of a clavicular fracture. Our reviewer says that CPT code 23515 does not meet criteria for billing or reimbursement consideration.  Our reviewer found CPT 23515 would not be inclusive to excision of tumor, but would be included in the global package. However, two surgeons performed different procedures, and there is a more appropriate way to report services. Operative report describes a midshaft fracture occured, during clavical retraction, which was treated by a orthopedic specialist. If an injury is treated by the primary physician during the initial surgery, this procedure would be inclusive to the global surgical package. In this case another surgeon performed a procedure through a different incision. In this case, two surgeons performed 2 different procedures, and appropriate modifier should be appended for the additional surgeon.  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 open treatment of a clavicular fracture have not been met. Therefore, we decided that the Plan does not have to pay for the open treatment of clavicular fracture (23515) provided on December 11, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (G0482) provided July 9, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the billed services.  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 G0482 is not supported in the medical record. Specifically, the place of service on the claim form (81, lab) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0482) provided July 9, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subarachnoid opioid injection provided on August 2, 2021.  You asked the Plan to pay for the subarachnoid opioid injection. You say that this was denied as an epidural steroid injection, but this was a subarachnoid opioid injection, which is medically necessary and should be covered. The Plan denied your request. The Plan says records were not submitted to support medical necessity.  The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. No records were submitted to confirm the services rendered, nor to support that coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the subarachnoid opioid injection provided on August 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Extracorporeal Pulse Activation Technology (EPAT) session provided on August 31, 2021, billed with code 97799.  You asked the Plan to pay for the EPAT session. You say that this is a medically necessary treatment which is helpful. The Plan denied your request. The Plan says this is not a treatment that is supported by peer-reviewed medical literature. It remains experimental 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 EPAT session. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.  Our physician reviewer found the enrollee received the EPAT treatment on August 31, 2021, which is noted to be her fifth physical therapy visit. The documentation does not include an objective physical examination. The subjective portion of the note states the patient reports relief after the previous condition. This is not considered medically necessary because the documentation on 8/31/21 does not reveal an objective physical examination supporting a diagnosis or a need for this treatment.   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 EPAT session have not been met. Therefore, we decided that the Plan does not have to pay for the Extracorporeal Pulse Activation Technology (EPAT) session provided on August 31, 2021, billed with code 97799.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Laparoscopy, surgical; repair initial inguinal hernia (49650-RT and 49650-LT) provided on August 4, 2021.  You asked the Plan to pay for codes 49650-RT and 49650-LT. 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 claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 49650 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. This code also has a bilateral surgery indicator of 1. This means the code should be reported with 1 unit of service and modifier 50 (bilateral modifier) to be considered for payment. Based on this information, we decided that Medicare rules for coverage of codes 49650-RT and 49650-LT have not been met. Therefore, we decided that the Plan does not have to pay for the Laparoscopy, surgical; repair initial inguinal hernia (49650-RT and 49650-LT) provided on August 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a surgical placement of implant body for tooth #2, #3, #9, #10, #13, #18, #19 (D6010).  You asked the Plan to pre-approve a surgical placement of implant body. You say that you need these implants due to not having two teeth in the front. You also say it is uncomfortable to eat. The Plan denied your request. The Plan says this service is not covered under your benefit 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.       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. Therefore, we decided that the Plan does not have to pre-approve a surgical placement of implant body for tooth #2, #3, #9, #10, #13, #18, #19 (D6010).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on April 20, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the billed codes cannot be verified.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   The file shows that a Tempus gene panel was provided. We looked at the file and the rules. The claim provided lists a place of service as an independent laboratory. The records do not show that the enrollee specimen was obtained at the independent laboratory. The claim also shows that multiple codes were billed for the gene panel. If a single procedure is performed, only one HCPCS/CPT code with one unit of service may be reported for the procedure. 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 lab services provided on April 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for rental of an air fluidized bed provided on August 20, 2021.  You asked the Plan to pay for rental of an air fluidized bed. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.  During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for rental of an air fluidized bed provided on August 20, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.

You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says the stay is not medically necessary based on LTACH criteria. The Plan
states they will continue to cover medically necessary acute and critical care at the current facility until the
enrollee's condition is stable for transfer to an alternate level of care, or until the clinical circumstances change
such that LTACH may be reconsidered.

The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says
that the requested LTACH care is not considered medically reasonable and necessary in this case. Our
physician reviewer found the enrollee appears to be more stable and improving and only short-term acute care
services are needed to further stabilize the enrollee that can be safely received at the current facility. The
enrollee does not require services at the LTACH that are not already available at the current facility. There are
no services at the LTACH that the enrollee requires that are not already available and covered at the current
facility. Transfer to LTACH would not be clinically advantageous and so will be considered not medically
necessary. Transfer to a lower level of care may be considered when treatment has completed.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan
does not have to pre-approve LTACH services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a diagnostic esophagogastroduodenoscopy (EGD).  You asked the Plan to pre-approve a diagnostic EGD. You say that this is medically necessary before the enrollee can receive surgery. The Plan denied your request. The Plan says the enrollee does not have a covered indication for the requested procedure.  The Plan follows Medicare rules. Medicare rules say that a diagnostic EGD is covered for indications listed 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 a diagnostic EGD. Our reviewer says that the requested EGD is not medically reasonable and necessary based on Medicare coverage criteria. Our physician reviewer found the record indicates that the enrollee is being evaluated for bariatric surgery. The record does not indicate symptoms of disease in which the presence of upper GI pathology might modify other planned management. The elements of the coverage criteria are not satisfied. The requested service is not recommended.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a diagnostic EGD have not been met. Therefore, we decided that the Plan does not have to pre-approve a diagnostic esophagogastroduodenoscopy (EGD).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from October 18, 2021, to October 19, 2021.    You asked the Plan to pay for the self-administered drugs. You say that you went because of your condition. You also say that the rest of your claim was paid. The Plan denied your request. The Plan says the drugs you received in the outpatient setting are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received in the outpatient setting are not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from October 18, 2021, to October 19, 2021.   Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for rental of an Air fluidized bed provided on  September 20, 2021.  You asked the Plan to pay for rental of an Air fluidized bed. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services.   The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for rental of an Air fluidized bed provided on  September 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 6, 2021 and billed under code 70450.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says there is a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists between codes 70496 and 70450.  This PTP edit has a modifier indicator of 1, which indicates modifiers associated with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit.   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, this claim cannot be paid due to the omission of the required modifier. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on August 6, 2021 and billed under code 70450.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services (00860) provided on June 15, 2021.  You asked the Plan to pay for the anesthesia services. 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 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 00860 is anesthesia for extraperitoneal procedures in lower abdomen, including urinary tract; not otherwise specified.  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 anesthesia services. Our reviewer says that CPT code 00860 does not meet criteria for billing or reimbursement consideration. Our reviewer found the provider states the procedure is a revision of an ileal conduit stoma.  This would be located in the lower abdomen, however, does not support urinary tract, as a stoma is on the abdominal wall.  There is a more appropriate code report for procedure on lower abdominal wall.  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 anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services (00860) provided on June 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an office visit provided on April 19, 2021.  You asked the Plan to waive the copayment for an office visit. The Plan denied your request. The Plan says the $25.00 copay applied correctly to the member's liability per the Evidence of Coverage.  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 $25 copayment for Vision Care Medicare-covered, exam to diagnose and treat diseases and conditions of the eye.      You have been asked to pay a $25 copayment for an office visit. This office visit falls within the Vision Care Medicare-covered, exam to diagnose and treat diseases and conditions of the eye 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 office visit provided on April 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve two (2) preventative dental visits to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve preventative dental visits. You say that you have been trying to get your teeth cleaned since July 2021 and you had to wait over 3 hours with one provider, and you had to pay $110 for x-rays with another provider. You also say you need to have your teeth cleaned with the requested provider. The Plan denied your request. The Plan says there are in-network providers available for these services.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.   The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal.   We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve two (2) preventative dental visits to be provided by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve lanthanum carbonate (J8499).  You asked the Plan to pre-approve lanthanum carbonate. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the requested drug is not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve lanthanum carbonate (J8499).   Benefits for lanthanum carbonate may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.