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

We decided that the Plan does not have to pay for the moderate sedation services rendered on May 13, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 99152 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

In this case, the CPT Code Manual definition of code 99152 is moderate sedation services by other qualified health care professional requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status, patient 5 years of age or older, first 15 minutes.

We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an independent trained observer to assist in monitoring the patient's level of consciousness and physiological status, first 15 minutes. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services rendered on May 13, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.

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 enrollee does not meet criteria for IRF admission. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 

The enrollee was admitted for surgical repair of a periprosthetic hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for a intensive, multi-disciplinary rehabilitation program. 

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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on April 20, 2021.
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the test was not ordered at the same time as the biopsy procedure.
The Plan must follow Medicare rules. Medicare rules say that ConfirmMDx testing is covered for males aged 40 to 85 years old that have undergone a previous cancer-negative prostate biopsy within 24 months and are being considered for a repeat biopsy due to persistent or elevated cancer-risk factors We looked at the file and Medicare rules. The file shows that the enrollee was not being considered for a repeat biopsy. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the ConfirmMDx testing rendered on April 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5100) received on May 13, 2021.
You asked the Plan to pay for hearing aids. You say that you want the Plan to reimburse you for the items. The
Plan denied your request. The Plan says the items at issue are not covered benefits.
The Plan must follow Medicare rules. The rules say that Medicare does not cover hearing aids or related
services.
Though hearing aids may be appropriate in this case, neither Medicare nor the Plan covers or pays for these
types of items and services. Therefore, we decided that the Plan does not have to pay for hearing aids (V5100)
received on May 13, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot or cold packs therapy provided on June 18, 2021.

You asked the Plan to pay for the hot or cold packs therapy. You say that authorization is not needed, and the claim should be reprocessed. The Plan denied your request. The Plan says payment for G0283, 97110 and 97150 has been approved. The plan also says that code 97010 is considered bundled with the paid codes and bundled services are not eligible for separate reimbursement.

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, CPT code 97010 has a status indicator of B. This means that CPT code 97010 is considered bundled and not separately payable. Based on this information, we decided that Medicare rules for coverage of the hot or cold packs therapy have not been met. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy provided on June 18, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on October 26, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services billed are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed in the Medicare rules section, are not covered.
The laboratory testing at issue in this appeal was requested solely for screening purposes. Medicare does not
cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the
laboratory services provided on October 26, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (01480) provided May 26, 2021.

You asked the Plan to pay for the anesthesia services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed code is not separately payable.

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 01480 is not supported in the medical record. Specifically, only one anesthesia code is reported unless the anesthesia code is an add-on code or has an appropriate modifier attached. CPT code 01924 has the highest base unit value and was billed and paid. 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 anesthesia services (01480) provided May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services of an open wound (97597) rendered by the out-of-network (OON) provider on May 26, 2021.

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 debridement services of an open wound (97597) rendered by the out-of-network (OON) provider on May 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a patient lift system (E0621, E0639, A9901) provided on
April 15, 2021, by a supplier not enrolled in the Medicare program.
You asked the Plan to pay for a patient lift system. You say that the Plan had approved prior authorization for
the services at issue. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is
not enrolled in the Medicare program.
Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare
program. Therefore, we decided that the Plan does not have to pay for a patient lift system (E0621, E0639,
A9901) provided on April 15, 2021, by a supplier not enrolled in the Medicare program.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided from January 8, 2020, to January 10,
2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says medical records were
not received.
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. The submitted documentation does not contain medical records from
the non-contract provider for the dates of service in question.
Without records, it cannot be confirmed that Medicare coverage criteria have been met. Therefore, we decided
that the Plan does not have to pay for the services provided from January 8, 2020, to January 10, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for physical therapy provided from April 6, 2021, through April 28, 2021.
You asked the Plan to waive the copayment for physical therapy. You say that You only had three massages. You say that the other therapists only did exercise that left you in more pain than you arrived. The Plan denied your request. The Plan says the copayments applied 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 a $40 copayment for physical therapy at an in-network outpatient hospital.
You have been asked to pay a total of $319.84 for the physical therapy.
Date of Service
Service
Standard Copayment
Member Liability
April 6, 2021
Physical Therapy
$40
$40
April 9, 2021
Physical Therapy
$40
$40
April 14, 2021
Physical Therapy
$40
$40
April 19, 2021
Physical Therapy
$40
$40
April 20, 2021
Physical Therapy
$40
$39.84
April 23, 2021
Physical Therapy
$40
$40
April 26, 2021
Physical Therapy
$40
$40
April 28, 2021
Physical Therapy
$40
$40
TOTAL:
$319.84
Physical therapy falls within the "Outpatient rehabilitation services" 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 physical therapy provided from April 6, 2021, through April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second medial branch block.
You asked the Plan to pre-approve a second medial branch block. You say that the requested second medial branch block is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the requested second medial branch block.
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 a second medial branch block. Our reviewer says that the enrollee does not meet criteria for the requested second medial branch block. Our physician reviewer found a repeat injection is supported for any of the following: 1) documentation that the prior diagnostic facet joint injection/medial branch block (MBB) produced at least 80% or more pain relief for the duration of the agent used, 2) at least 80% improvement after two diagnostic injections prior to a therapeutic injection, or 3) the last therapeutic injection provided at least 50% improvement of pain for at least three months or at least 50% improvement in performing activities of daily living. The clinical information provided does not describe one of these and, therefore, the requested procedure is not indicated at this time. The review has determined that the enrollee does not meet the above LCD criteria for the requested second medial branch block. 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 second medial branch block have not been met. Therefore, we decided that the Plan does not have to pre-approve a second medial branch block.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from May 1, 2021, to May 3, 2021.
You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee required no nursing services which would be considered skilled services by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a skilled nursing facility (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 pay for the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from May 1, 2021, to May 3, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Dilantin.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your
request. The Plan says the requested drug is intended for patient self-administration.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Dilantin.
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve a bi-level respiratory assist device without back-up rate (BiPAP) (E0470) and heated humidifier (E0562) for the enrollee.
You asked the Plan to pre-approve a BiPAP and heated humidifier. You say that these are medically necessary for the enrollee. The Plan denied your request. The Plan says that that there is no clinical evidence to support the medical necessity for a replacement BiPAP machine.
The Plan follows Medicare rules. Medicare rules say that a BiPAP can be covered if LCD criteria have been met. 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 BiPAP and heated humidifier. Our reviewer says that a BiPAP is medically reasonable and necessary for the enrollee in this case. The patient is a male with severe obstructive sleep apnea with prior use of BiPAP since 2014. A replacement BiPAP machine (with auto titrating feature) was requested. The machine is not damaged or malfunctioning according to the notes, but the auto feature was the reason for requesting an upgraded device. The patient appears to still require BiPAP. The replacement BiPAP is medically reasonable and necessary for the enrollee as there is evidence of a malfunctioning BiPAP he is currently using when you consider he is using the device correctly according to the notes, but he is not feeling any difference with or without the device suggesting a malfunction or need for auto-titration throughout the night when in use. The device is over 7 years old. The upgrade with likely improve the patient's health and quality of life. Our physician reviewer found that the enrollee's condition meets Medicare criteria for a BiPAP. 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 BiPAP and heated humidifier have been met. Therefore, we decided that the Plan has to pre-approve a bi-level respiratory assist device without back-up rate (BiPAP) (E0470) and heated humidifier (E0562) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the L300 Go Lower System.
You asked the Plan to pre-approve the L300 Go Lower System. You say that the requested L300 Go Lower System is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for the L300 Go Lower System.
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 L300 Go Lower System. Our reviewer says that the enrollee does not meet criteria for the L300 Go Lower System. Our physician reviewer found in this case, according to the applicable NCD, the requested technology is only covered for use when a patient has a history of a spinal cord injury (SCI) and additional requirements for coverage are met. In this case the member is noted to have Multiple Sclerosis with right-sided foot drop, and they have no history of a SCI. Rather they have neurological changes secondary to multiple sclerosis. This ultimately would not meet/satisfy the initial requirements of the NCD for coverage of the requested item. 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 L300 Go Lower System have not been met. Therefore, we decided that the Plan does not have to pre-approve the L300 Go Lower System.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Synthroid tablet.
You asked the Plan to pre-approve Synthroid tablet. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Synthroid tablet.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion/specialty drug administration coded 99601 provided on March 2, 2021.
You asked the Plan to pay for the home infusion/specialty drug administration. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not payable.
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 99601 is home infusion/specialty drug administration, per visit (up to 2 hours).
We find that CPT code 99601 is not supported in the medical record. Specifically, this code has a status code of "I". A status code of I means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment of these services. Based on this information, we decided that Medicare rules for coverage of the home infusion/specialty drug administration have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion/specialty drug administration coded 99601 provided on March 2, 2021.