Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure (CPAP) device provided on July 16, 2021.

You asked the Plan to waive the coinsurance for a CPAP device. You say that the device was recalled and you should not have to pay for something you cannot use. 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 20% coinsurance for durable medical equipment and related supplies. 

You received a CPAP device on July 16, 2021. The total allowed amount is $89.37 and 20% of that is $17.87.

You have been asked to pay the total coinsurance amount of $17.87 for a CPAP device. A CPAP device falls within the durable medical equipment and related supplies benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the coinsurance for a continuous positive airway pressure (CPAP) device provided on July 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) brain, including brain stem (70551).

You asked the Plan to pre-approve the MRI. You say that the medical records provided will support the necessity of the requested service. The Plan denied your request. The Plan says the requested MRI of the brain is not medically necessary for the diagnosis of short-term memory loss.

The Plan must follow Medicare rules. Medicare rules say that MRIs 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 the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the record indicates that the enrollee has restless leg syndrome and short-term memory loss. The record does not indicate the occurrence of acute injury. The record does not include a neurologic or mental status examination. The requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this time. The elements of the coverage criteria are not satisfied. 

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 MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) brain, including brain stem (70551).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on March 22, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (70450) provided on March 22, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen and pelvis (70450) provided on June 19, 2021.

You asked the Plan to pay for the CT scan of the abdomen and pelvis. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this claim was not billed with an appropriate modifier as required 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. In this case, we have confirmed that code 70450 has a bundled relationship with 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the abdomen and pelvis (70450) provided on June 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve six additional months' supply for a continuous glucose monitor.

You asked the Plan to pre-approve the additional supplies. You say that this is medically necessary. The Plan denied your request. The Plan says a six month supply can be approved.

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 additional supplies. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates a diagnosis of diabetes, and the plan has approved a continuous glucose monitor. The next six month supply will require a visit that has not yet occurred. The elements of the coverage criteria are not satisfied. 

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 supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve six additional months' supply for a continuous glucose monitor.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
You asked the Plan to pre-approve the compression stockings. You say that you believe they should be covered since they are preventing the need for surgery on your veins. The Plan denied your request. The Plan says this item is not a covered Medicare benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6530 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6530.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that there are no skilled nursing or rehab needs.
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 SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 95957, 95908, and 95886 provided on November 18, 2020.
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says the documentation does not corroborate the billed codes.
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 95886 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure). The CPT Code Manual definition of code 95908 is nerve conduction studies; 3-4 studies. The CPT Code Manual definition of code 95957 is digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis). 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 medical services. Our reviewer says that the medical documentation does not support the codes as billed. Our reviewer found that regarding CPT code 95886, the medical records provided do not include sufficient documentation to support that a Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; complete, five or more muscles studied, innervated by three or more nerves or four or more spinal levels (List separately in addition to code for primary procedure) was performed on November 18, 2020 as pedicle screw stimulations do not meet criteria of baseline nerve conduction studies. For code 95908, the medical records provided do not include sufficient documentation to support that a nerve conduction studies; 3-4 studies as pedicle screw stimulations are not baseline nerve conduction studies. Therefore, this service cannot be verified. Finally, for code 95957, the medical records provided do not include sufficient documentation to support that a Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis) was performed on November 18, 2020, therefore this procedure cannot be verified. A real time electroencephalogram monitoring is not covered under CPT code 95957. 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 medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 95957, 95908, and 95886 provided on November 18, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), provided on May 24, 2021.
You asked the Plan to pay for the comprehensive periodontal evaluation. You say that the service should be covered. The Plan denied your request. The Plan says the 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. Specifically, the service obtained is not listed in the Plan's benefit chart. This means the service is not covered. Therefore, we decided that the Plan does not have to pay for the comprehensive periodontal evaluation (D0180), provided on May 24, 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 IRF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for IRF care have not been met.

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 that the patient was admitted for coronavirus pneumonia and was discharged home on September 20, 2021. Medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. In conclusion, there is not a reasonable expectation that this patient 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a panniculectomy.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that a panniculectomy is covered when specific criteria are 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the submitted records show that you underwent bariatric surgery and had a 78 pound weight loss. The photographs do not indicate that your pannus is below the pubis area. The records state that the rashes beneath the pannus have responded to conservative management. The criteria for coverage are not met and the panniculectomy is therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a panniculectomy.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) coded 70551 provided on May 12, 2021.
You asked the Plan to pay for the MRI. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 70551 is magnetic resonance (eg, proton) imaging, brain (including brain stem); without contrast material.
We find that CPT code 70551 is not supported in the medical record. Specifically, this service was billed with place of service 11 (outpatient); however, the documentation supports a different place of service where these services were rendered. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pay for the magnetic resonance imaging (MRI) coded 70551 provided on May 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthroscopy, shoulder, surgical; biceps tenodesis (CPT
code 29828-RT) and arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures
(e.g., humeral bone, humeral articular cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps
anchor complex, labrum, articular capsule, articular side of the rotator cuff, bursal side of the rotator cuff,
subacromial bursa, foreign body[ies]) (CPT code 29823-59-RT) provided to the enrollee on May 28, 2021.

You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your
request. The Plan says the services are not supported by the 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.

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 services. Our reviewer found the documentation
submitted was reviewed and does not meet criteria. Operative report documents a biceps tenotomy with radio
frequency wand with later tenodesis was performed, however did not include details of the procedure to
confirm Medicare criteria has been met. For CPT 29823, operative report also documents "extensive
debridement"; however, description of 3 or more discrete structures (e.g., humeral bone, humeral articular
cartilage, glenoid bone, glenoid articular cartilage, biceps tendon, biceps anchor complex, labrum, articular
capsule, articular side of the rotator cuff, bursal side of the rotator cuff, subacromial bursa, foreign body[ies])
was not included to confirm extensive debridement per Medicare guidelines. Therefore, CPT 29828 and CPT
29823 cannot be confirmed as performed and would not be covered.

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 services have not been met. Therefore, we decided that the Plan does not
have to pay for CPT code 29828-RT and CPT code 29823-59-RT provided to the enrollee on May 28, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and complete series of radiographic images (x-rays) (D0210), provided on May 12, 2021.

You asked the Plan to pay for a comprehensive oral evaluation and complete series of x-rays. You say that the services should be covered. The Plan denied your request. The Plan says you did not obtain these services in-network.

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. Specifically, you did not receive these services in-network. This means the services are not covered. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and complete series of radiographic images (x-rays) (D0210), provided on May 12, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve transit tie-downs (K0108) for a wheelchair.
You asked the Plan to pre-approve transit tie-downs. You say that the requested item is a necessity for your care. The Plan denied your request. The Plan says the requested item is not a covered benefit.
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 transit tie-downs (K0108) for a wheelchair
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the continuous airway pressure (CPAP) and related supplies
received on December 14, 2020 and December 25, 2020.

You asked the Plan to pay for the CPAP and related supplies. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the items received are not a covered
benefit when provided by a non participating provider.

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 the continuous airway pressure (CPAP) and related supplies received on December 14, 2020 and December 25, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Freestyle Libre continuous glucose monitor (CGM).
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the criteria for coverage are not met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that you do not treating with insulin three or more times per day. 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 a Freestyle Libre continuous glucose monitor (CGM).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the urography services coded 74420 provided on April 8, 2021.

You asked the Plan to pay for the urography 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 supported by the documentation.

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 74420 is urography, retrograde, with or without KUB. 

We find that CPT code 74420 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of a urography, retrograde with or without KUB; therefore, the billed service cannot be verified. Based on this information, we decided that Medicare rules for coverage of the urography services have not been met. Therefore, we decided that the Plan does not have to pay for the urography services coded 74420 provided on April 8, 2021.