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

 We decided that the Plan does not have to pay for prolotherapy, a transcutaneous electrical nerve stimulator (TENS) and supplies, and a pneumatic device; examinations before, during and/or after treatment provided to the enrollee on June 15, 2021.  You asked the Plan to pay for prolotherapy medical services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says these services are not covered by the Plan or by Medicare rules.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Medicare rules say outpatient physical therapy services are subject to the criteria listed in the Medicare rules section. Medicare rules say compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.  We find that the denied therapy services are not supported in the medical record. Specifically, we find that the physical therapy services (97112, G0283) at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the state the services were performed.  Additionally, the multiple drug codes reported on this claim (J3411, J3415, J3490, J7999) refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made.
Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid.
Based on this information, we decided that Medicare rules for coverage of the prolotherapy services billed have
not been met. Based on this information, we decided that Medicare rules for coverage of prolotherapy medical
services have not been met. Therefore, we decided that the Plan does not have to pay for prolotherapy, a
transcutaneous electrical nerve stimulator (TENS) and supplies, and a pneumatic device; examinations before,
during and/or after treatment provided to the enrollee on June 15, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the immunohistochemistry rendered on September 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 the services are 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 88312 is special stain including interpretation and report; Group I for microorganisms (eg, acid fast, methenamine silver). 

We find that CPT code 88312 is not supported in the medical record. Specifically, the file shows that the services were performed for nail pathologies and this code is not appropriate for those services. 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 immunohistochemistry rendered on September 13, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the preventive procedure (D1999) provided on October 26, 2021.

You asked the Plan to pay for the preventive procedure. You say that you had an emergency and needed to visit the dentist. The Plan denied your request. The Plan says this service is not a covered benefit.

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 pay for the preventive procedure (D1999) provided on October 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the consultation (D9310) provided on September 27, 2021.
You asked the Plan to pay for the consultation. You say that you have been paying for the dental rider coverage
but have not used it over the last two years due to the Coronavirus. You also say that you would like to know
what the purpose of the rider is if nothing is covered under your plan. The Plan denied your request. The Plan
says this service is not a covered benefit under your dental 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 pay for the
consultation (D9310) provided on September 27, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the revision of reconstructed breast (19380) provided on
March 3, 2021.
You asked the Plan to pay for the revision of reconstructed breast (19380). You say that the services that
represent CPT code 19380 were medically necessary and are documented in the medical records. You say that
you disagree with the decision and the claim should be reviewed. The Plan denied your request. The Plan says
CPT code 19380 was not billed correctly.
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 19380 is 1. The MAI value for this code is 2. You billed 2 units of this
code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the
revision of reconstructed breast (19380) have not been met. Therefore, we decided that the Plan does not have
to pay for the revision of reconstructed breast (19380) provided on March 3, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) services.
You asked the Plan to pre-approve a CT scan. You say that the requested CT scan is for follow-up and to
evaluate for stability of the opacities. The Plan denied your request. The Plan says a CT scan of the chest is not
medically necessary.
The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are
medically necessary.
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 CT scan. Our reviewer says that the
criteria for coverage have not been met. Our physician reviewer found the enrollee had a recent CT of the chest
in September of 2021. It is too soon to reassess a 4mm small nodule. The requested CT scan is 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 a CT scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve computed tomography (CT) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a transthoracic echocardiogram (93306).
You asked the Plan to pre-approve a transthoracic echocardiogram. You say that this service is medically
necessary for the enrollee's condition. 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 transthoracic echocardiogram for palpitations is
subject to the criteria 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 transthoracic echocardiogram. Our
reviewer says that the requested service is not medically reasonable and necessary. Our physician reviewer
found 50-year-old man with history of episodic numbness and palpitations for which transthoracic
echocardiogram (TTE) is requested to assess for cardiac etiology. At issue is the medical necessity for
performance of a TTE in a patient with normal cardiovascular examination and electrocardiogram (ECG), as
well as brain imaging. Guidelines do not support a need for TTE in this setting. As a result, at this time TTE
would not be considered medically appropriate and necessary in this patient's clinical management.
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 transthoracic echocardiogram have not been met. Therefore, we decided that
the Plan does not have to pre-approve a transthoracic echocardiogram (93306).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjacent tissue transfer (14001) provided on March 12,
2021.
You asked the Plan to pay for the adjacent tissue transfer (14001). You say that the documentation should be
reviewed and considered for payment. The Plan denied your request. The Plan says breast reconstruction
procedures include the adjacent tissue transfer or rearrangement procedures when performed together on the
same date of service at the same site.
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 14001 is adjacent tissue transfer or rearrangement, trunk;
defect 10.1 sq cm to 30.0 sq cm.
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 adjacent tissue transfer (14001). Our reviewer says that
this does not meet the criteria for billing or reimbursement consideration. Our reviewer found that CPT code
14001 was performed on the same side as CPT code 19301 and is not eligible for reimbursement consideration.
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 adjacent tissue transfer (14001) have not been met. Therefore, we decided
that the Plan does not have to pay for the adjacent tissue transfer (14001) provided on March 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the hernia repair (49650) provided on April 20, 2021.
You asked the Plan to pay for the hernia repair (49650). You say that the claim needs to be processed and remit payment to the provider. The Plan denied your request. The Plan says this surgical procedure must be reported with 1 unit of service and modifier 50.
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. Based on this information, we decided that Medicare rules for coverage of the hernia repair (49650) have not been met. Therefore, we decided that the Plan does not have to pay for the hernia repair (49650) provided on April 20, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug services rendered on June 24, 2021 to June 26,
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 J3490 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 J3490 is unclassified drugs.
We find that CPT code J3490 is not supported in the medical record. Specifically, the records show that a
sterile water, saline and/or dextrose, diluent/flush, 10 mL was performed and there is a more appropriate code
for these services. 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 drug services rendered on
June 24, 2021 to June 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (82306) provided March 24, 2021.
You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The Plan denied your request. The Plan says the services were for screening purposes and are non-covered.
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 test 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 lab services (82306) provided March 24, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is
medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does
not meet criteria.
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 improving and only needs additional short-term acute care
services that can be safely administered 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 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 long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the PBRT for prostate cancer (CPT code(s): 77520, 77295, 77301, 61800, 77338, 61796, 63620, 77432, 77435, 77387), for the enrollee.
You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says medical studies have not shown that PBT is better than other treatments for this type of cancer.
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 services. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is insufficient data available at this time to determine whether or not Proton Beam radiation treatment for prostate cancer is superior, inferior, or equivalent to external beam radiation, intensity-modulated radiation therapy (IMRT), or brachytherapy in terms of safety or 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the PBRT for prostate cancer (CPT code(s): 77520, 77295, 77301, 61800, 77338, 61796, 63620, 77432, 77435, 77387), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for acute IRF admission and services.
You asked the Plan to pay for IRF care. You say that the stay is medically necessary. The Plan denied your
request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the enrollee's
care is routine in nature and they do not need a team of providers. The Plan states the enrollee can safely
receive the services they need in other settings, for example: a skilled nursing facility, home with home health
services or home with outpatient therapy.
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 pay for 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 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 a fall, congestive heart failure, and urinary tract infection. 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, and an intensive rehabilitation therapy program.
While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for
an intensive rehabilitation program. There is not a reasonable expectation that this enrollee will be able to fully
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.
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 pay for acute IRF admission and services.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the hot or cold packs therapy (97010) provided by Phoenix
Rehabilitation on September 22, 2021.
You asked the Plan to pay for the hot or cold packs therapy (97010). You say that authorization is not needed,
and the claim should be reprocessed. The Plan denied your request. The Plan says CPT codes 97140, 97110
and 97112 were approved for payment. CPT code 97010 remains denied as 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 (97010) have not
been met. Therefore, we decided that the Plan does not have to pay for the hot or cold packs therapy (97010)
provided by Phoenix Rehabilitation on September 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ankle foot orthosis equipment (L1971, L3170) provided on May 6, 2021.
You asked the Plan to pay for durable medical equipment. You say that you would like this claim reprocessed based on the medical documentation The Plan denied your request. The Plan says sufficient documentation to warrant coverage was not provided.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record does not contain relevant medical records which support medical necessity for the supplies provided
in this case. Specifically, the medical records do not include documentation that the provider discussed the need for the provided equipment with the enrollee. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the ankle foot orthosis equipment (L1971, L3170) provided on May 6, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
You asked the Plan to pre-approve continued services. You say that you need more time with physical therapy. The Plan denied your request. The Plan says you are at a maintenance level of care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve continued services. Our physician reviewer found that from a nursing perspective, you received oral medications and had stable vital signs. There are no identifiable skilled nursing service needs. Regarding rehabilitation services, by the date in question, you were non-ambulatory and dependent for functional mobility. You required maximum to total assist with activities of daily living. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a 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 continued services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.