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

We decided that the Plan does not have to pay for the adjacent tissue transfer (14301 and 14302) provided on April 19, 2021.
You asked the Plan to pay for the adjacent tissue transfer (14301 and 14302). You say that the procedure is dictated on the operative report. You say that just because specific wording isn't used doesn't mean the services were not performed and payment should be issued. The Plan denied your request. The Plan says procedure codes 14301 and 14302 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 definition of code 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The CPT Code Manual definition of code 14302 is adjacent tissue transfer or rearrangement, any area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure) 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 (14301 and 14302). Our reviewer says the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the operative report does not describe an adjacent tissue transfer. The operative report describes undermining, and CPT 14301 is an incorrect code to report for this procedure. CPT 14302 is an "add-on" code and would only be approved if the primary procedure is approved. In this case, an adjacent tissue transfer was not documented in the operative report and cannot be confirmed as performed. 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 (14301 and 14302) have not been met. Therefore, we decided that the Plan does not have to pay for the adjacent tissue transfer (14301 and 14302) provided on April 19, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve lymphedema therapy consultation and services to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve out-of-network services. You say that you saw this provider for a period in 2018. You trust them and would like to continue to receive services from this provider. The Plan denied your request. The Plan says out-of-network services are only covered in certain limited circumstances. The requested care is not urgent or emergent, and you last saw this provider a few years ago. Your care can safely be performed by an in-network 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 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 lymphedema therapy consultation and services to be provided by an out-of-network (OON) provider
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided on September 15, 2021.

You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that you disagree with the charges. 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 $20 copayment for outpatient rehabilitation services. 

You have been asked to pay a $20 copayment for outpatient rehabilitation services. Outpatient rehabilitation services fall 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 outpatient rehabilitation services provided on September 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an additional 18 physical therapy (PT) visits.

You asked the Plan to pre-approve the additional PT visits. You say that it is felt that more PT is needed. The Plan denied your request. The Plan says additional therapy at this time 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 the 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 the additional requested therapy is not generally accepted as specific and effective therapy for the patient's condition beyond what was approved by the health plan. The patient has had prior therapy and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or under the supervision of a therapist. The patient has been instructed in and is compliant in a home exercise program. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the patient's current condition or to prevent or slow further deterioration. 

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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve an additional 18 physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6545.

You asked the Plan to pre-approve the compression stockings. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the enrollee does not meet the criteria as the records show that the enrollee has venous insufficiency without a qualifying wound.

The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6545 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. 

The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6545.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion Interspinous device for the
enrollee.
You asked the Plan to pre-approve these services. You say that this is medically necessary for the enrollee. The
Plan denied your request. The Plan says that the device is contraindicated for the enrollee.
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 these services. Our reviewer says that
the requested services are not considered medically reasonable and necessary in this case. The vertilfex device
is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the
enrollee's condition does not meet criteria for coverage of these services.
We looked at this physician's review, the file, and Medicare rules. 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 pre-approve the Vertiflex Superion Interspinous device for the enrollee.
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 records provided support the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee could receive care in another setting.
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 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 respiratory failure, coronavirus pneumonia, and encephalopathy. The enrollee's 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 the 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 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 pre-approve radiofrequency ablation.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the records show that there have been two radiofrequency ablations in the lumbosacral region this year.
The Plan must follow Medicare rules. Medicare rules say that two radiofrequency ablation sessions per calendar year are covered. The records show the same procedure was done 5/18/21 and again on 6/1/21. 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 radiofrequency ablation.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on May 12, 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 billed correctly.

The Plan must follow Medicare rules. The rules say that for Medicare purposes, only one anesthesia code is reported unless the anesthesia code is an add-on code. 

We looked at the file and Medicare rules. The file shows that more than one anesthesia code was reported. 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 anesthesia services rendered on May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex Superion interspinous spacer for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there is a lack of evidence to support interspinous devices as safe and effective as the gold standard of surgical decompression.

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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The Vertiflex spacer is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for these services. 

We looked at this physician's review, the file, and Medicare rules. 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 pre-approve the Vertiflex Superion interspinous spacer for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a specialist visit provided on June 14, 2021.
You asked the Plan to waive the copayment for a specialist visit. You say that you did not receive any services on this date of service. 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 $25 copayment for specialist visits. The medical records show that you had a specialist visit on June 14, 2021. Therefore, you are responsible to pay the $25 copayment. You have been asked to pay a $25 copayment for a specialist visit. A specialist visit falls within the physician/practitioner services, including doctor's office visits 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 a specialist visit provided on June 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that this is medically necessary. The Plan denied your request. The Plan says this is being requested for use outside of the home.
The Plan must follow Medicare rules. The rules state that for equipment to be covered, it must be appropriate and needed for use inside the home. The item at issue in this appeal is for use outside of the home. Although this item may be helpful, neither Medicare nor the Plan covers equipment for use outside the home. Therefore, we decided that the Plan does not have to pre-approve a power wheelchair.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the cardiovascular stress test (93017) provided on September 2, 2021.

You asked the Plan to waive the copayment for the stress test. You say that your provider told you this service was necessary in order to get anesthesia for your colonoscopy. You did not want this service but were told it was necessary, and now you are being billed. The Plan denied your request. The Plan says this claim was processed correctly, and your copayment was assessed in accordance with your contract.

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 $150 copayment for each advanced imaging service (e.g., MRI, CT and PET scans, nuclear medicine and stress tests). 

You have been asked to pay a $150 copayment for the stress test. A stress test falls within the advanced imaging 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 the cardiovascular stress test (93017) provided on September 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient rehabilitation services provided by a non-contracted provider on June 23, 2021.

You asked the Plan to waive the copayment for outpatient rehabilitation services. You say that this provider was in-network, and you should not be charged an out-of-network copayment. The Plan denied your request. The Plan says the correct copayment has been 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 $55 copayment for outpatient rehabilitation services/out-of-network provider. 

You have been asked to pay a $55 copayment for outpatient rehabilitation services. The provider who rendered these services is out-of-network; therefore, the correct copayment has been applied.

Outpatient rehabilitation services fall within the outpatient rehabilitation services/out-of-network provider 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 outpatient rehabilitation services provided by a non-contracted provider on June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultrasound guidance for needle placement provided on June 17, 2021, and July 1, 2021, billed with code 76942.
You asked the Plan to pay for the ultrasound guidance as billed. You say that this was denied but both the injection and the ultrasound were needed to treat the enrollee's condition. The Plan denied your request. The Plan says payment has been made for the injections; however, there is no evidence that the use of ultrasound guidance is reasonable and necessary for this treatment.
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 76942 is ultrasonic guidance for needle placement (eg, biopsy, aspiration, injection, localization device), imaging supervision and interpretation. We find that CPT code 76942 is not supported in the medical record. Specifically, the operative notes for both dates of service make no mention of the use of ultrasound guidance for needle placement.
Based on this information, we decided that Medicare rules for coverage of the ultrasound guidance as billed have not been met. Therefore, we decided that the Plan does not have to pay for the ultrasound guidance for needle placement provided on June 17, 2021, and July 1, 2021, billed with code 76942.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (64494) provided July 29, 2021.
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the number of units billed exceeds the allowed amount. 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 64494 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 injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (64494) provided July 29, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the injection of a non-compounded foam sclerosant with
ultrasound compression maneuvers (36465) provided on August 20, 2021, by an OON provider.

You asked the Plan to pay for the out-of-network services. You say that these services were rendered in an
outpatient office setting. These services were medically necessary and referred by the nursing facility where the
enrollee resides. The Plan denied your request. The Plan says these services were provided by an out-of-network
provider in an out-of-network facility. The services at issue were not urgent or emergent and could
have been received from an in-network provider. No valid referral or authorization for these services are on
file.

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. 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 the injection of a non-compounded foam
sclerosant with ultrasound compression maneuvers (36465) provided on August 20, 2021, by an OON provider.