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

We decided that the Plan does not have to pay for debridement of bone services (11044) provided on March 14, 2022.

You asked the Plan to pay for code 11044. You say that the medical records provided support that payment is due for the code in dispute. The Plan denied your request. The Plan says payment for the code in dispute was inclusive to another billed code.

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 11044 is a column II code to column I code 28261; however, 11044 was billed with a modifier.

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 code 11044. Our reviewer says that the criteria for coverage have not been met. Our reviewer found the provider reported Current Procedural Terminology (CPT) 11044 Debridement of bone (includes epidermis, dermis, subcutaneous tissue, muscle and/or fascia, if performed) for the first 20 square centimeter (sq cm) or less in addition to midfoot capsulotomy procedure. The operative report describes procedures performed on the left foot, and same surgical field. In this case, debridement would be included with the primary procedure reported, CPT 28261 midfoot capsulotomy, with tendon lengthening.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of code 11044 have not been met. Therefore, we decided that the Plan does not have to pay for debridement of bone services (11044) provided on March 14, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit coded 99214 provided on 
September 22, 2022.

You asked the Plan to pay for the office visit. You say that you disagree with the Plan's denial. 
The Plan denied your request. The Plan says the services billed 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.

We find that CPT code 99214 is not supported in the medical record. Specifically, this service was 
billed on the same date of service as minor surgical procedure 20610 (Arthrocentesis, aspiration 
and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without 
ultrasound guidance). Payment for code 99214 is included in the payment of surgery procedure 20610 
provided on the same date of service and is therefore, not
separately payable.

Based on this information, we decided that Medicare rules for coverage of the office visit have not been met. Therefore, we decided that the Plan does not have to pay for the office visit coded 99214 provided on September 22, 2022.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code J3490 provided on March 4, 2022.

You asked the Plan to pay for procedure code J3490. You say that this service was medically 
necessary. The Plan denied your request. The Plan says the code billed is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that providers must report services 
correctly. Providers must report services with the appropriate CPT code.

We find that CPT code J3490 is not supported in the medical record. Specifically, this code is 
included in the global surgery package of another code billed on the same day. Based on this 
information, we decided that Medicare rules for coverage of procedure code J3490 have not been met. 
Therefore, we decided that the Plan does not have to pay for procedure code J3490 provided on March 4, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous glucose monitor. 
 
You asked the Plan to pre-approve the requested device. You say that the enrollee's blood sugars can be better 
controlled. The Plan denied your request. The Plan says the enrollee does not meet the criteria. 
 
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 does not indicate that the enrollee uses insulin 
with at least three daily injections or requires frequent self-adjustment of insulin dosage based on the blood 
glucose testing results. Based on this information, we decided that Medicare rules for coverage of the requested 
device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous 
glucose monitor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need physical therapy to walk again and regain 
maximum function after surgeries on both feet. The Plan denied your request. The Plan says based on Medicare 
guidelines, the IRF services requested do not meet the requirements for approval. 
 
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 you do not require the intensity of services provided at an IRF. Specifically, 
you are not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. 
Your 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 IRF admission and services.
Appeal type: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 7 more home health physical therapy visits. 
 
You asked the Plan to pre-approve 7 more home health physical therapy visits. You say that 7 more home 
health physical therapy visits are medically necessary. The Plan denied your request. The Plan says 7 more 
home health physical therapy visits are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically 
necessary for the enrollee to receive skilled nursing or 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 7 more home health physical therapy 
visits. Our reviewer says that 7 more home health physical therapy visits are not medically necessary. Our 
physician reviewer found the documentation doesnt support that the member requires additional skilled rehab 
services to provide treatment that is medically necessary. The member does not require additional skilled rehab 
services to effectively provide treatment, care, and/or services in order to improve the members condition, perform a maintenance program to maintain the members condition and/or prevent deterioration. The member 
has been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. 
The requested home health services are 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 7 more home health physical therapy visits have not been met. Therefore, we 
decided that the Plan does not have to pre-approve 7 more home health physical therapy visits.
Appeal type: SNF
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the SNF care is medically necessary. The Plan 
denied your request. The Plan says the SNF care is not medically necessary. 
 
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 care. Our reviewer says that the 
requested SNF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized 
skill, knowledge, and judgment of a skilled professional nurse. The enrollee does not have daily skilled therapy 
needs that require the specialized skill, knowledge, and judgment of a skilled professional therapist. The 
enrollee does not require daily skilled nursing and/or skilled therapy on an inpatient basis in a skilled nursing 
facility (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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
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 doctor strongly believes the enrollee meets the 
requirements for IRF care. The Plan denied your request. The Plan says the IRF care is not medically 
necessary, and the enrollee's needs can be met at a lower level of care such as 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 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 based on the documentation provided, the enrollee does not require the intensity of 
services provided at an IRF.  Specifically, the enrollee is not shown to require fifteen hours per week of 
rehabilitative services and regular physician evaluation. The enrollees 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for procedure code 99497 billed for date of service July 12, 2022.

You asked the Plan to pay for procedure code 99497. You say that this service was medically necessary. The Plan denied your request. The Plan says payment for code 99497 is bundled into payment for code 99220.

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 99497 is a column II code to column I code 99220. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for procedure code 99497 billed for date of service July 12, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a ventilator (E0466). 
 
You asked the Plan to pre-approve a ventilator. You say that the services are necessary. The Plan denied your 
request. The Plan says based on the documentation provided, coverage criteria has not been met. 
 
The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically 
necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory 
failure due to COPD. 
 
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 ventilator. Our reviewer says that the 
services are not medically necessary. Our physician reviewer found the record indicates that the enrollee has 
chronic hypercarbic respiratory failure from chronic obstructive pulmonary disease with bronchiectasis. The 
record indicates that average volume-assured pressure support (AVAPS) with acute exacerbation (AE) has 
been ordered. The provided primary source documentation does not contain sufficient detailed information in 
the medical record to justify the treatment selected. The enrollee could be treated with a bilevel positive airway pressure (BiPAP) machine with AVAPS capability. The plan has indicated coverage for such a device is 
available upon request. The elements of the coverage criteria are not satisfied. The requested service cannot be 
recommended. 
 
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 ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator (E0466).
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided from February 7, 2022, to March 8, 2022.

You asked the Plan to pay for home health services. You say that the services at issue have been 
billed correctly. The Plan denied your request. The Plan says rules for payment have not been met.

The Plan must follow Medicare rules. Medicare rules say that the HHA shall submit an NOA with a 
one-time, artificial 'admission' date corresponding to the "From" date of the first period of 
continuing care in 2022.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules 
for coverage of home health services have not been met. Specifically, the case record does not 
support that an NOA with a one-time, artificial admission date for 2022 has been submitted to the 
Plan. Therefore, we decided that the Plan does not have to pay for home health services provided from February 7, 2022, to 
March 8, 2022.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from January 17, 2022 to February 15, 2022.

You asked the Plan to pay for the home health services as billed. You say that the home health services were medically necessary. The Plan denied your request. The Plan says the claim has not been billed with the correct admission date.

The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a NOA must be submitted for the first period of care in 2022, using the first date of the period as the "admission" date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to
the correct NOA.

We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue does not match the date for the NOA which is filed for the first date in 2022 as required. Based on this information, we find that the Medicare rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided from January 17, 2022 to February 15, 2022.
Appeal type: DME/ Orthotics
Decision: Favorable

 
We decided that the Plan has to pre-approve Accu-Chek Aviva Plus test strips. 
 
You asked the Plan to pre-approve Accu-Chek Aviva Plus test strips. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says that the requested items are not covered. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. In this case, the Plan denied a request for a non-preferred brand diabetes test 
strip stating that there is no indication that the enrollee cannot use the Plan's preferred diabetes test strips. 
However, the file shows that the Plan made no attempts to obtain medical records from the treating physician. 
The Plan also did not provide the Evidence of Coverage and/or Plan documentation that enrollees have access 
to that shows what the preferred brand diabetes test strips are. We find that the Plan has not provided enough 
evidence to support their denial. Therefore, we decided that the Plan has to pre-approve Accu-Chek Aviva Plus 
test strips.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Prolia/Xgeva injections. 
 
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied 
your request. The Plan says the enrollee has not been diagnosed with osteoporosis. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 injections. Our reviewer says that 
the requested injection is not medically reasonable or necessary. Our physician reviewer found that the 
documentation indicates that the member's last bone density test (2021) showed a T-score of -1.7. This does not 
meet the definition of osteoporosis. The review has determined that the documentation does not support that the Prolia is medically reasonable and necessary for the patient. The documentation does not support that the Prolia 
is safe and effective for the patient. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Prolia/Xgeva injections.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts (93978) and ultrasound guidance for vascular access (76937) provided on August 2, 2022, and August 10, 2022.

You asked the Plan to waive the copayments for the duplex scan of aorta and ultrasound guidance for vascular access. You say that you received an ultrasound on June 18, 2021, and no copay applied. The Plan denied your request. The Plan says this cost sharing was charged correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $125 copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a physician's office or at a free-standing facility under the Outpatient Diagnostic Tests and Therapeutic Services and Supplies benefit category.

You have been asked to pay a $125 copayment for the duplex scan of aorta. You have also been asked to pay $44.18 for the ultrasound guidance for vascular access, which is less than the standard $125 copayment. These services fall within the Outpatient Diagnostic Tests and Therapeutic Services and 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 copayments for the duplex scan of aorta, inferior vena cava, iliac vasculature, or bypass grafts (93978) and ultrasound guidance for vascular access (76937) provided on August 2, 2022, and August 10, 2022.