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

We decided that the Plan does not have to pay for a pneumatic compression device and appliances provided on February 23, 2021.

You asked the Plan to pay for a pneumatic compression device (E0675) and appliances (E0673). You say that the device was prescribed by the physician for use during surgery. The Plan denied your request. The Plan says a PCD is not covered by Medicare to prevent deep vein thrombosis and the facility must furnish all necessary covered services.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0675) is a preventive service. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.

This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device and appliances provided on February 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an exception to the 75 mile limit for routine
transportation.

You asked the Plan to pre-approve exceptions to supplemental benefits. You say that you must make these trips
for prostate cancer treatment. The Plan denied your request. The Plan says that the requested amount exceeds
the limit.

Medicare does not cover routine transportation. While plans may offer supplemental transportation benefits,
they are not required to do so. Medicare does not provide exceptions to supplemental benefits. Therefore, we
decided that the Plan does not have to pre-approve an exception to the 75 mile limit for routine transportation.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from February 1, 2021,
to February 22, 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's
condition no longer required daily skilled services at an inpatient skilled nursing facility (SNF) 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 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 February 1, 2021, to February 22,
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services provided on March 19, 2021, billed with codes 15734-RT and 15734-LT.
You asked the Plan to pay for the surgical services as billed. You say that this was billed correctly and should be paid. The Plan denied your request. The Plan says these codes were 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 15734 is Muscle, myocutaneous, or fasciocutaneous flap; trunk.
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 surgical services as billed. Our reviewer says that the documentation does not support the billing of these codes. Our reviewer found the operative report does not include documentation of a flap closure, but a repair with retrorectus mesh. There is a more appropriate code to report for this procedure. Therefore, CPT 15734 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 surgical services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services provided on March 19, 2021, billed with codes 15734-RT and 15734-LT.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to reimburse for non-covered item or service (A9270) provided February 10, 2021 to February 24, 2021.
You asked the Plan to reimburse for the non-covered item or service. You say that you paid the $20 copayment twice. Once in the office and you also mailed a money order for $20. You need to be reimbursed $20 for overpayment. The Plan denied your request. The Plan says the claims were processed with the correct cost share applied per the Evidence of Coverage.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $20 copayment for each Medicare covered podiatry visit. You have asked for reimbursement of $20. The Plan confirmed with the provider that the amount paid of $30 was for date of service February 10, 2021 for the cost of orthopedic shoes that you were informed by the provider was not covered. The copayment was not paid on the February 10, 2021 date of service which is why you were sent a bill and you sent a $20 money order for that date of service. For the services received February 24, 2021, you paid the $20 copayment on the date of service.
The non-covered item or service falls within the Podiatry 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 reimburse for non-covered item or service (A9270) provided February 10, 2021 to February 24, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (87631) provided on February 6, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered 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, the CPT Code Manual definition of code 87631 is "Infectious agent detection by nucleic acid (DNA or RNA); respiratory virus (eg, adenovirus, influenza virus, coronavirus, metapneumovirus, parainfluenza virus, respiratory syncytial virus, rhinovirus), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 3-5 targets." 

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 says that the use of code 87631 is not supported by the records provided. Our reviewer found that code 87631 is an incorrect code to report for coronavirus screening. Additionally, the documentation supports that more than 5 targets were tested. 

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 the services (87631) provided on February 6, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a seat lift chair purchased on January 15, 2021.
You asked the Plan to pay for this item. You say that this seat lift chair was medically necessary. The Plan denied your request. The Plan says you purchased this item without prior authorization from a provider who is not a Medicare eligible provider.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who is not a Medicare eligible provider. Medicare has specific coverage criteria for seat lift mechanisms. Medicare does not cover a seat lift chair which covers the mechanism.
This item was purchased out of network without prior authorization form a provider who is not a Medicare eligible provider. Therefore, we decided that the Plan does not have to pay for a seat lift chair purchased on January 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home infusion therapy services provided from May 30, 2021, to July 13, 2021.
You asked the Plan to pay for the services provided. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim for services denied correctly.
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 S9328 is home infusion therapy, implanted pump pain management infusion; administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem
We find that CPT code S9328 is not valid for Medicare purposes. Medicare uses another code for the reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy services provided from May 30, 2021, to July 13, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the outpatient surgery services provided on October 1, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the services provided.
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 $350 copayment for each visit to an outpatient hospital facility. You have been asked to pay a $350 copayment for the surgery services provided at an outpatient hospital facility visit.
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 outpatient surgery services provided on October 1, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional PT visits.
You asked the Plan to pre-approve ten (10) additional PT visits. You say that the patient reported that she is using her arms more around the house. She noted that she can see the overall improvement in her walking and stability. The Plan denied your request. The Plan says additional PT 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 ten (10) 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 enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior therapy extensive therapy for this condition 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 for physical therapy, by or under the supervision of a therapist. The enrollee has been instructed 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 enrollee'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 ten (10) additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for telephone evaluation and management visit, 21-30 minutes of medical discussion (99443) provided on May 21, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the telephone visit. You say that the enrollee encountered for dental abscess and the provider rendered telephonic evaluation and management service to the enrollee. Submitting this request with supporting documentation attached to support billed charges. The Plan denied your request. The Plan says the diagnosis on this claim is not covered by the Plan.
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. The records show there is no referring provider. 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 telephone evaluation and management visit, 21-30 minutes of medical discussion (99443) provided on May 21, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the evaluation and management services provided on March 17, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the services provided. You say that the service was provided with no adequate time frame to obtain prior authorization. The Plan denied your request. The Plan says authorization is required for out-of-network providers.
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 file shows that the enrollee was seen for a follow-up visit for shoulder pain. 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 evaluation and management services provided on March 17, 2020 by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve to pre-approve a tier exception for Mycophenolic Acid for the enrollee.
You asked the Plan to pre-approve a tier exception. You say that the patient needs this medication for his renal transplant. The Plan denied your request. The Plan says that tier exceptions are not available for drugs covered by Part B.
The Plan must follow Medicare rules. Medicare rules say that tier exceptions are only available for Part D drugs. The requested drug is covered under Part B. Based on this information, we decided that Medicare rules for coverage of a tier exception have not been met. Therefore, we decided that the Plan does not have to pre-approve to pre-approve a tier exception for Mycophenolic Acid for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Coronavirus testing provided on June 20, 2020.

You asked the Plan to pay for the Coronavirus testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not payable.

The Plan must follow Medicare rules. Medicare rules say that services provided from a freestanding emergency facility are not covered. 

We looked at the file and Medicare rules. Review of the file shows that the services were rendered in a freestanding emergency facility. These type of facilities are not hospitals and not affiliated with a hospital; therefore, are not able to obtain Medicare approval/certification.

Based on this information, we decided that Medicare rules for coverage of the Coronavirus testing have not been met. Therefore, we decided that the Plan does not have to pay for the Coronavirus testing provided on June 20, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for computed tomography (CT) scans (70450, 70460) provided
on May 25, 2021.
You asked the Plan to pay for CT scans. You say that the enrollee had multiple exams. The Plan denied your
request. The Plan says these services are 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. In this case, we have confirmed that codes
70450 and 70460 have 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 computed tomography (CT) scans (70450, 70460)
provided on May 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) for the enrollee.
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says no daily skilled needs are noted.
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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found the enrollee has stabilized medically and is ready for discharge from the hospital. The enrollee does not require skilled nursing and/or skilled therapy services on a daily basis. She is medically stable and can receive further rehab services at a lower level of care. She is stable on her current/chronic ventilator settings. Her physical function is at or near her baseline and she can receive services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF) 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 you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically necessary.
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 enrollee was admitted for a diabetic foot wound and cellulitis of percutaneous endoscopic gastrostomy (PEG) site. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. 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. Therefore, the enrollee's care needs can be met at a lower level of care. 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.