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

We decided that the Plan does not have to pay for the anesthesia for procedures on major vessels of neck (00350) and billed with -78 modifier provided on April 8, 2021.
You asked the Plan to pay for the anesthesia services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has not been coded correctly based on Medicare coding regulations.
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 00350 is anesthesia for procedures on major vessels of neck; not otherwise specified. We looked at the file and Medicare rules. In this case, the anesthesia services have been billed with modifier 78. Modifier 78 is an unplanned return to the operating room following initial procedure for a related procedure during the postoperative period. This modifier is only appropriate to submit with surgery codes. It is not among those modifiers to be used with anesthesia services. Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia for procedures on major vessels of neck (00350) and billed with -78 modifier provided on April 8, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from September 3, 2021, to September 9, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that things took a turn for the worst once you got to the hospital, and you do not remember the first couple of days. You also say that you were not able to leave until you were medically stable. The Plan denied your request. The Plan says that this request for coverage is not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record shows that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from September 3, 2021, to September 9, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded 99239 and 94003 provided from November 24, 2020, through November 27, 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 support the services 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 99239 is hospital discharge day management; more than 30 minutes. The CPT Code Manual definition of code 94003 is ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day.

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 documentation does not support the services as billed. Our reviewer found the medical records provided do not include sufficient documentation to validate that code 94003, ventilation assist and management, initiation of pressure or volume preset ventilators for assisted or controlled breathing; hospital inpatient/observation, each subsequent day was provided on November 24, 2020. Therefore, this service cannot be verified. Furthermore, the medical records provided do not include sufficient documentation to validate that 99239, Hospital discharge day management; more than 30 minutes was performed on November 27, 2020. Therefore, this procedure cannot be verified. 

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 99239 and 94003 provided from November 24, 2020, through November 27, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and adjunctive prediagnostic test (D0431) provided on October 22, 2021.

You asked the Plan to pay for the dental services. You say that you went to an annual cleaning and x-ray. You say that you only received the usual x-rays. You say that there was no discussion of additional x-rays. You also say that you should not have to pay this bill. The Plan denied your request. The Plan says the claim was denied correctly.

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 and comprehensive oral evaluation is listed as covered, the frequency limit has been exceeded. The Evidence of Coverage says 1 periodontal or comprehensive evaluation is covered every 3 years. The record shows that the plan paid for a periodontal evaluation that you received on May 24, 2019. Additionally, the adjunctive prediagnostic test is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the comprehensive oral evaluation (D0150) and adjunctive prediagnostic test (D0431) provided on October 22, 2021.
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 that the enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH 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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the FreeStyle Libre continuous glucose monitor (CGM)(K0553) provided on July 8, 2021.
You asked the Plan to pay for the FreeStyle Libre CGM supplies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support the supplies billed.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. There is no indication in the file that the member's treating physician discussed the need for a CGM with the member. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the FreeStyle Libre continuous glucose monitor (CGM)(K0553) provided on July 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Urinary Tract Infection - Identification + Antibiotic Resistance testing (87640, 87653, 87481, 87798) provided on August 18, 2021.
You asked the Plan to pay for the Urinary Tract Infection - ID + Antibiotic Resistance testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this claim was billed with an inappropriate place of service code.
The Plan must follow Medicare rules. Medicare rules say that for purposes of payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Urinary Tract Infection - ID + Antibiotic Resistance testing have not been met. Specifically, this claim was billed with the laboratory place of service code while the records suggest that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the Urinary Tract Infection - Identification + Antibiotic Resistance testing (87640, 87653, 87481, 87798) provided on August 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Minuteman interspinous process procedure.
You asked the Plan to pre-approve the requested services. You say that the enrollee has tried all conservative treatments. The Plan denied your request. The Plan says experimental procedures are not covered by Medicare.
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 requested services. Our physician reviewer found that the enrollee has chronic low back pain from lumbar spinal stenosis, an L4 disc protrusion and ligamentum flavum hypertrophy. The patient has tried physical therapy, Celebrex, Valium, and steroid injections. The request is for the placement of an interspinous process spacer. This procedure has not been endorsed by two separate learned orthopedic societies. It is considered experimental/investigational and therefore, it is deemed not medically reasonable or 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 the requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Minuteman interspinous process procedure.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 the enrollee is receiving appropriate care at the present acute care hospital. 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. 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: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the physical therapy (97110, 97112, 97116, 97140, 97530), to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve the physical therapy. You say that the service is medically necessary. The Plan denied your request. The Plan says the member must use network providers to get medical care and services.

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 physical therapy (97110, 97112, 97116, 97140, 97530), to be provided by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a knee x-ray provided on November 10, 2021.

You asked the Plan to waive the copayment for a knee x-ray. You say that you were told there would not be a copayment. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 a $50 copayment for x-rays done at an outpatient hospital. You have been asked to pay a $50 copayment for a knee x-ray. A knee x-ray falls 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 copayment for a knee x-ray provided on November 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (procedure code 49905) provided to the enrollee on March 16, 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 records do not support the services 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 49905 is "Omental flap, intra-abdominal (List separately in addition to code for primary procedure)." 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 services at issue in this case were not supported by the medical records. Our reviewer found the medical records provided do not include sufficient documentation based on the CPT code's definition and guidance to validate that an Omental flap, intra-abdominal (List separately in addition to code for primary procedure) was performed on March 16, 2021, therefore this procedure cannot be verified.
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 surgical services (procedure code 49905) provided to the enrollee on March 16, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ziextenzo.

You asked the Plan to pre-approve Ziextenzo. The Plan denied your request. The Plan says you have not tried and failed two of the preferred drugs, Neulasta, Fulphila, and Udenyca.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 Ziextenzo. Our physician reviewer found that you have malignant neoplasm of the prostate with metastases to bone, lymph nodes, and liver. The Plan requires a trial of two of the preferred drugs, Neulasta, Fulphila, and Udenyca before they will approve the requested drug. The case file does not contain documentation of trial and failure of 2 of the plan's 3 preferred drugs. The documentation does not support that the Plan's required drugs would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ziextenzo have not been met. Therefore, we decided that the Plan does not have to pre-approve Ziextenzo.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded as 38220, 29823, and 20610 provided on June 15, 2021.

You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says the documentation does not support the CPT codes 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 20610 is arthrocentesis, aspiration and/or injection, major joint or bursa (eg, shoulder, hip, knee, subacromial bursa); without ultrasound guidance. The CPT Code Manual definition of code 29823 is arthroscopy, shoulder, surgical; debridement, extensive, 3 or more discrete structures (eg, 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]). The CPT Code Manual definition of code diagnostic bone marrow; aspiration(s). 

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 documentation does not support payment for the codes as billed. Our reviewer found the operative report does not describe extensive debridement 3 or more discrete structures. To cite the operative report "We identified the complex full-thickness rotaor cuff tear as well as a degenerative labral tear which was debrided extensively". "At this point, we had completed our debridement"; "We debrided the margin of the rotator cuff, and proceeded to place the SutureBridge with good fixation using FiberTape". Documentation does not support 3 or more descrete structures documented in the operative report. 

In addition, regarding CPT 20610 there is no guideline found to support a stem cell injection cannot be reported separately from the primary procedure; however, in this case the stem cell harvesting was not correctly documented, to support the transplant of stem cell injection. 

Finally, code 38220 is not supported for payment as the operative report does not describe the procedure of a bone marrow aspiration, and cannot be verified when this procedure was performed, and how. To cite the operative report "Initially, a bone marrow aspirate occurred with the Jamshidi needle. We were able to get 620 mL of marrow without difficulty". 

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 38220, 29823, and 20610 provided on June 15, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Paxil tablets.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this self-administered drug does not fall under Part B coverage.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Paxil tablets.