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

We decided that the Plan does not have to pay for the supervision of a nursing facility enrollee coded 99380 provided on March 30, 2021.

You asked the Plan to pay for the supervision of a nursing facility enrollee. 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 99380 is supervision of a nursing facility patient (patient not present) requiring complex and multidisciplinary care modalities involving regular development and/or revision of care plans by that individual, review of subsequent reports of patient status, review of related laboratory and other studies, communication (including telephone calls) for purposes of assessment or care decisions with health care professional(s), family member(s), surrogate decision maker(s) (eg, legal guardian) and/or key caregiver(s) involved in patient's care, integration of new information into the medical treatment plan and/or adjustment of medical therapy, within a calendar month; 30 minutes or more. 

We find that CPT code 99380 is not supported in the medical record. Specifically, this code has a status indicator of "B". This means that this code is always bundled into payment for other services not specified and no separate payment can be made. Based on this information, we decided that Medicare rules for coverage of the supervision of a nursing facility enrollee have not been met. Therefore, we decided that the Plan does not have to pay for the supervision of a nursing facility enrollee coded 99380 provided on March 30, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
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 the services you require can safely be received at a different setting.
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 your 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.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 2 power operated vehicle (K0806).

You asked the Plan to pre-approve a group 2 power operated vehicle. You say that this request is medically necessary to improve your condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.

The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 

The file shows that you do not have a mobility deficit that impairs your participation in MRADLs.This means that Medicare rules for coverage of a PMD have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 2 power operated vehicle (K0806).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found based on the documentation provided the enrollee appears to not be stable enough for transfer at this time. Acute care services can be safely administered at the current facility for the time being until treatment is completed and transfer to a lower level of care is more appropriate. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is 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 complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do 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. 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: 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 monitor. You say that this is medically necessary. The Plan denied your request. The Plan says the criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who perform blood glucose testing at least four times per day, use insulin with at least three daily injections, and 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 assesses adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. The file shows that insulin is injected twice per day. Based on this information, we decided that Medicare rules for coverage of the monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health care services provided from February 17, 2021, to March 1, 2021.
You asked the Plan to pay for home health care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation does not support the codes billed and this provider is not enrolled in the Medicare program so is not eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that to receive payment for covered items and services, a provider must be enrolled in Medicare. We looked at the file and Medicare rules. This provider is not enrolled in Medicare and is not eligible for payment. Based on this information, we decided that Medicare rules for coverage of home health care have not been met. Therefore, we decided that the Plan does not have to pay for home health care services provided from February 17, 2021, to March 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for radiation therapy services provided on January 8, 2021 and January 11, 2021.

You asked the Plan to pay for radiation therapy services. You say that all procedures are part of the patient's treatment plan and are normal payable procedures. You say that you attached the medical records for further processing. The Plan denied your request. The Plan says the services remain denied.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare criteria for coverage have not been met. Specifically, the documentation submitted does not include any clinical information to verify if the services were rendered or medically necessary on the billed date of service. Sufficient information has not been submitted in order to determine whether payment is due and the amount of payment. Therefore, we decided that the Plan does not have to pay for radiation therapy services provided on January 8, 2021 and January 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a chiropractic office visit received on May 27, 2021.
You asked the Plan to pay for the services. You say that past chiropractic claims were paid. The Plan denied your request. The Plan says the previous paid claims were billed with a spinal manipulation code.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the service at issue is not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for a chiropractic office visit received on May 27, 2021.
Appeal type: Imaging
Decision: Favorable

We decided that the Plan has to pay for the services (G0279) provided on February 4, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that the add-on code was not billed with an appropriate primary code.
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. 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 G0279 is "Diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066)". The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. We find that CPT code G0279 is supported in the medical record. Specifically, code G0279 has been billed appropriately in addition to code 77065. The Plan has not provided documentation to substantiate its denial. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for the services (G0279) provided on February 4, 2021.
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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the prophylaxis (D1110) provided on May 20, 2021.
You asked the Plan to pay for the prophylaxis. You say that this visit was specifically required before radiation treatment could begin. The Plan denied your request. The Plan says you have met your dental allowance for the current plan year.
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 Plan offers a $325 allowance per year for preventive dental services. The record shows that you met the annual maximum benefit while processing this claim for the May 20, 2021 date of service and your annual maximum benefit has been exhausted. Therefore, we decided that the Plan does not have to pay for the prophylaxis (D1110) provided on May 20, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services rendered from August 3, 2020, to 
August 28, 2020. 
 
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 claims were billed incorrectly.

The Plan must follow Medicare rules. The rules say that home health claims must report one of three Q codes 
and revenue code matching what was submitted on the RAP. 
 
We looked at the file and Medicare rules. The file shows that the claims were not billed with the appropriate Q 
code(s) and rev code matching the correct service lines. 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 home health services rendered from August 3, 2020, to August 28, 2020.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transportation (A0428) and
ground mileage (A0425) provided on March 24, 2021.

You asked the Plan to pay for the transportation services. You say that the enrollee required a basic life support
stretcher transport. You also say that any lesser mode of transport was contraindicated and may have
compromised the enrollee's health and wellbeing. The Plan denied your request. The Plan says the non-emergent
ambulance transport was not medically necessary.

Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan
follows the same rules.

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 transportation services. Our reviewer
says that the transportation services are not medically necessary. Our physician reviewer found the provided
documentation does not indicate a physical or mental condition that was a contraindication to a stretcher van
transport on March 24, 2021. The reviewer found that the records indicate the enrollee had a stable exam and
stable vital signs throughout the transport with only a complaint of weakness. the reviewer also found that the
ambulance transport on March 24, 2021, was not medically reasonable and necessary for the enrollee.

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 transportation services have not been met. Specifically, the file shows that
another form of transportation could have been used safely. Therefore, we decided that the Plan does not have
to pay for the non-emergent ambulance transportation (A0428) and ground mileage (A0425) provided on
March 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on March 11, 2021 by an out-of-network provider.
You asked the Plan to pay for the office visit. You say that the claim should not need authorization. The Plan denied your request. The Plan says the services were not authorized.
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 service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for the service. Therefore, we decided that the Plan does not have to pay for the office visit provided on March 11, 2021 by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).

You asked the Plan to pre-approve an upper and lower partial denture. You say that your previous dentures got messed up. You are in pain and cannot eat. The Plan denied your request. The Plan says you have exceeded the frequency limit for these services.

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. The Plan covers an upper and lower partial denture once every five years.

We looked at the file and Medicare rules. The Plan provided documentation showing that a partial upper and lower denture were covered on December 13, 2019. Based on this information, we decided that the Plan's frequency limit for coverage of an upper and lower partial denture has been exceeded. Therefore, we decided that the Plan does not have to pre-approve a maxillary partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5213) and mandibular partial denture - cast metal framework with resin denture bases (including retentive/clasping materials, rests and teeth) (D5214).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81263, 88184, 88185, 88368 
and 88377 provided on April 16, 2021. 
 
You asked the Plan to pay for the laboratory services. 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. 
 
We find that CPT codes 81263, 88184, 88185, 88368 and 88377 are not supported in the medical record. 
Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when 
the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a 
laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates 
that the specimen was obtained in an office setting place of service 11. Based on this information, we decided
that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the 
Plan does not have to pay for the laboratory services coded 81263, 88184, 88185, 88368 and 88377 provided 
on April 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve percutaneous implantation of neurostimulator electrode
array, epidural (63650) 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 records show the enrollee does not have a condition for which this
treatment is medically necessary.
The Plan follows Medicare rules. Medicare rules say that no payment may be made for the implantation of
dorsal column or depth brain stimulators or services and supplies related to such implantation, unless patients
have undergone careful screening, evaluation and diagnosis by a multidisciplinary team prior to implantation
and that such screening must include psychological, as well as physical evaluation.
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
these services are not medically reasonable and necessary for the enrollee in this case. It's not entirely clear
from the notes provided that the member has a nerve root injury. Furthermore, it is not clear that the member
has undergone a surgical consultation (for possible intervention) prior to the provision of a spinal cord
stimulation. Our physician reviewer found that the enrollee's condition does not meet Medicare 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 percutaneous implantation of neurostimulator electrode array, epidural (63650) for the
enrollee.