Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90834) provided on September 2, 2021 to September 15, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for psychotherapy services. You say that you believed you were in-network. The Plan denied your request. The Plan says these 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90834) provided on September 2, 2021 to September 15, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for hearing aids provided on July 7, 2021.

You asked the Plan to reimburse you for the hearing aids. The Plan denied your request. The Plan says the
hearing aids were not ordered by the Plan's hearing aid provider.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when ordered through the Plan's hearing aid provider.

We looked at the file and the Plan's rules. The file shows that the hearing aids were not ordered through the
Plan's hearing aid provider. Based on this information, we decided that the Plan's rules for coverage of the
hearing aids have not been met. Therefore, we decided that the Plan does not have to reimburse you for hearing
aids provided on July 7, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia for the enrollee.
You asked the Plan to pre-approve Prolia. You say that this is medically necessary for treatment of the patient's age-related osteoporosis. The Plan denied your request. The Plan says that this is not covered under Part B.
The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill. In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Prolia for the enrollee.
Please note, the Plan confirmed that Prolia has been approved under the enrollee's Part D plan. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the assistant surgeon services for the skin grafts (15273 and
15274) provided on September 9, 2021.

You asked the Plan to pay for the assistant surgeon services for the skin grafts (15273 and 15274). You say that
the operative notes are attached for review and the claim should be reprocessed for payment. The Plan denied
your request. The Plan says CPT codes 15002 and 15003 have been overturned. The Plan also says that an
assistant surgeon may not be paid for CPT codes 15273 and 15274.

The Plan follows Medicare rules. Medicare rules state that for codes with an assistant at surgery indicator of 1,
assistant surgeon services are not covered. In this case, you billed assistant surgery services for Current
Procedural Terminology (CPT) code 15273 and 15274. The Medicare Fee Schedule Database contains a
surgical indicator of 1 for this procedure.

This means that Medicare has determined that an assistant surgeon is not medically necessary and will not be
paid. Based upon this information, we find that Medicare coverage criteria for the assistant surgeon services for
the skin grafts (15273 and 15274) have not been met. Therefore, we decided that the Plan does not have to pay
for the assistant surgeon services for the skin grafts (15273 and 15274) provided on September 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for drug testing services provided to the enrollee on April 26, 2021.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain 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 G0483 is "Drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed."

We find that procedure code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services provided to the enrollee on April 26, 2021.
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 the stay is medically necessary. The Plan denied
your request. The Plan says the stay is not medically necessary based on IRF criteria.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described in the Medicare rules section.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee
was admitted for abdominal pain. Medical problems are stable. There are no complex nursing or rehabilitation
needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or
occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for
physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation
program. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit
from the intensive rehabilitation therapy program provided in an IRF.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve acute IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the percutaneous laminotomy/laminectomy (0275T).
You asked the Plan to pre-approve the percutaneous laminotomy/laminectomy. You say that you would like
reconsideration because you have tried other treatments without relief and your pain is increasing. The Plan
denied your request. The Plan says this procedure is not covered for your condition.
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 percutaneous
laminotomy/laminectomy. Our reviewer says that the requested items/services are not considered medically
reasonable and necessary in this case.
Our physician reviewer found the records do not show that you have LSS. The PILD procedure is considered
experimental for your condition and more research is needed to show its safety and efficacy.
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 percutaneous laminotomy/laminectomy have not been met. Therefore, we
decided that the Plan does not have to pre-approve the percutaneous laminotomy/laminectomy (0275T).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care from December 1, 2021, forward.
You asked the Plan to pre-approve inpatient mental health car. You say that discharging the enrollee now puts them and the community at risk. The Plan denied your request. The Plan says the enrollee does not have a plan or intent to harm themselves. The enrollee does not have a plan or intent to harm others, they are not hearing voices telling them to harm themselves or anyone else, they are not aggressive or violent, there are no medical issues that require treatment at this level of care, and the enrollee has no severe side effects from medications. The Plan states the enrollee could be treated safely and effectively at a lower level of care.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 inpatient mental health car. Our physician reviewer found this enrollee does meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of December 1, 2021, forward and could not have been treated in a lesser restrictive setting as although the enrollee was not showing any suicidal or homicidal ideation, they did have auditory no visual hallucinations and aggressive behaviors while being uncooperative and non-compliant with treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient mental health car have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient mental health care from December 1, 2021, forward.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the visit and surgery (CPT code(s): 19371, 19342, 19380, and 15777) to be provided by an out-of-network provider.

You asked the Plan to pre-approve the services. You say that the services are medically necessary. The Plan denied your request. The Plan says there are in-network providers available.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. 

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the visit and surgery (CPT code(s): 19371, 19342, 19380, and 15777) to be provided by an out-of-network provider.
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 transfer to an LTACH is medically
necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an
LTACH are not met. The enrollee does not have a complex infection, complex wound care needs, or require
daily doctor visits with several treatment changes. The enrollee's continued care can be provided outside of a
hospital setting.
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 there is no documentation provided indicating medical necessity for LTACH
services. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not
require services at the LTACH that are not available at the acute care hospital where they are currently
receiving care. There are no services available at the LTACH that the enrollee requires that are not available at
the health care setting being offered by the health plan. The requested LTACH services are not medically
necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished
safely and effectively only on an inpatient basis.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F2 prothrombin gene analysis.
You asked the Plan to pre-approve the testing. You say that this is needed to see if there is a genetic
predisposition to blood clots. The Plan denied your request. The Plan says this is not a covered benefit.
The Plan must follow Medicare rules. Medicare rules say that F2 testing is only covered for pregnant patients.
The enrollee does not qualify for this testing. Based on this information, we decided that Medicare rules for
coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pre-approve F2
prothrombin gene analysis.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan of the head or brain.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your
request. The Plan says magnetic resonance imaging (MRI) is more likely to help in this case, and would be
approved if ordered.
The Plan must follow Medicare rules. Medicare rules say that CT scans 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 scan. Our reviewer says that the
requested scan is not medically reasonable or necessary. Our physician reviewer found it appears that you have
not had follow-up imaging after resection of the frontal lobe astrocytoma. The plan's position that MRI is a
better test is valid. MRI will be better in order to evaluate the symptomatic scalp lesion as well as the brain.
The records showed no apparent contraindication to MRI, and this exam would be more appropriate for total
cranial evaluation, as you have prior brain tumor and non-healing scalp wound.
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 scan have not been met. Therefore, we decided that the Plan does not have
to pre-approve computed tomography (CT) scan of the head or brain.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the critical care services (99291) provided on June 11, 2021.

You asked the Plan to pay for the critical care services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says there is no documentation of the amount of critical care time spent in this case.

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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation in the medical records regarding the total time that critical care services were provided on June 11, 2021. Based on this information, we decided that Medicare rules for coverage of the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for the critical care services (99291) provided on June 11, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a surgical placement of implant body: endosteal implant
(D6010), sinus augmentation (D7952), and bone replacement graft for ridge preservation (D7953).
You asked the Plan to pre-approve the endosteal implant, sinus augmentation, and bone replacement graft. You
say that these services were deemed medically necessary. The Plan denied your request. The Plan says these
services are not covered under your benefit plan.
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. Therefore, we decided that the Plan does not have to pre-approve a
surgical placement of implant body: endosteal implant (D6010), sinus augmentation (D7952), and bone
replacement graft for ridge preservation (D7953).
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after January 16, 2022.
You asked the Plan to pre-approve SNF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that that there is no documentation of intense and complex care needs.
The Plan must follow Medicare Rules. The rules say that Medicare plans must tell an enrollee that the Plan will stop paying for skilled nursing facility services. The Plan must issue a NOMNC no later than two days before the last covered day. This notice must include a description of the enrollee's right to an appeal. We looked at the file and the Medicare rules. The file does not show that a valid NOMNC was delivered two or more days before January 16, 2022. The Plan must pay for SNF services until the 100-day SNF care benefit is exhausted or daily skilled care is no longer needed and proper notice is issued. Therefore, we decided that the Plan has to pre-approve continued skilled nursing facility (SNF) services after January 16, 2022.
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: 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 is 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 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 injection or require 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 monitor
have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose
monitor.