Persius/hicric huggingface dataset:
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 IRF care is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met; the enrollee's needs can be met in an alternate setting.    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 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. 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. 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve dexamethasone tablets.  You asked the Plan to pre-approve self-administered drug. You say that the enrollee needs this drug. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because this drug is not covered by Medicare Part B and the Plan does not administer the enrollee's Medicare Part D prescription drug benefits.  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 dexamethasone tablets.   Benefits for self-administered drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the physician or allowed practitioner certification for Medicare-covered home health services (G0180) provided on August 9, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the physician or allowed practitioner certification for Medicare-covered home health services. You say that you would like this claim to be reconsidered and reprocessed for payment. The Plan denied your request. The Plan says these services were not authorized by network/primary care 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 requested provider in this case is not a network provider with the Plan. 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 the physician or allowed practitioner certification for Medicare-covered home health services (G0180) provided on August 9, 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 epidurography (72275-26-59) and additional time of moderate sedation (99153) provided along with an epidural steroid injection (ESI) on July 12, 2021.  You asked the Plan to pay for the epidurogram and additional moderate sedation time. You say that this is medically necessary and should be paid in full. The modifier -59 was used to indicate that the imaging was separate from the injection. The Plan denied your request. The Plan says code 72275 is included in payment for the ESI itself. In addition, 99153 is not payable to a physician in the facility setting.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that 99153 is a practice-only expense and is not payable to the physician in the facility setting.  In this case, the CPT Code Manual definition of code 72275 is epidurography, radiological supervision and interpretation.  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 epidurogram and additional moderate sedation time. Our reviewer says that the records do not support separate payment for code 72275 in this case. Our reviewer found the procedure report describes an injection given using radiological supervision at L4 and L5. A radiological supervision would be needed for this procedure and is included with this procedure. There is no indication of a separate epidurogram unrelated to the ESI.  The services at issue were provided in a facility setting. Medicare does not make payment for 99153 to the physician in the facility setting as this code does not include physician work.   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 epidurogram and additional moderate sedation time have not been met. Therefore, we decided that the Plan does not have to pay for the epidurography (72275-26-59) and additional time of moderate sedation (99153) provided along with an epidural steroid injection (ESI) on July 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for selective catheter placement (36012), transcatheter placement of an intravascular stent (37239), transluminal balloon angioplasty (37248), venography (75820 and 75825) and the measurement of venous pressure (93770) provided on August 26, 2021.  You asked the Plan to pay for the selective catheter placement, transcatheter placement of an intravascular stent, translumunal balloon angioplasty, venography and measurement of venous pressure. 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 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.  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 selective catheter placement, transcatheter placement of an intravascular stent, translumunal balloon angioplasty, venography and measurement of venous pressure. Our reviewer says that CPT code 37239 does not meet criteria for billing or reimbursement consideration. The operative report does not include documentation of additional stenting including angioplasty. CPT code 37248 does not meet criteria for billing or reimbursement consideration. The operative report does not support modifier 51, indicating multiple surgeries performed on the same day. CPT code 75820 does not meet criteria for billing or reimbursement consideration. The operative report does not include documentation of different anatomic sites to confirm these procedures as distinct from the primary procedure. Our reviewer found CPT code 36012 does not meet criteria for billing or reimbursement consideration. An edit exists between CPT code 36012 and CPT code 36478. An appropriate modifier was not billed with CPT code 36012 to bypass this edit. CPT code 93770 does not meet criteria for billing or reimbursement consideration. CPT code 93770 has a status indicator of B. Payment for this service is always included in the payment for another service or procedure.  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 selective catheter placement, transcatheter placement of an intravascular stent, translumunal balloon angioplasty, venography and measurement of venous pressure have not been met. Therefore, we decided that the Plan does not have to pay for selective catheter placement (36012), transcatheter placement of an intravascular stent (37239), transluminal balloon angioplasty (37248), venography (75820 and 75825) and the measurement of venous pressure (93770) provided on August 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the crown (D2740), core buildup, including any pins when required (D2950), and adjunctive procedure (D9999) provided on April 30, 2021 by a Medicare opt out provider.  You asked the Plan to pay for the crown, core buildup, and adjunctive procedure. You say that you never received the Evidence of Coverage from the Plan, and you were not advised you had to go online to find this document. You also say that the only information that was given to you in the 2021 enrollment package said that you have a $1,000 reimbursement for dental, but no mention of having to use a Medicare accepted provider. The Plan denied your request. The Plan says you received these services from a provider who chose not to receive Medicare funds. The Plan also says that the treating provider opted out of Medicare effective October 5, 2015, through October 5, 2023.  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 covered when they are received by a provider who has opted out of Medicare. Therefore, we decided that the Plan does not have to pay for the crown (D2740), core buildup, including any pins when required (D2950), and adjunctive procedure (D9999) provided on April 30, 2021 by a Medicare opt out provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit (99214), a drug test (80307) and electric stimulation therapy (97014) provided on May 21, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for an office visit, a drug test, and electric stimulation therapy. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is not a network provider with the Plan, and they have also determined that these services are not urgent or emergent, nor were they approved in advance.  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 an office visit (99214), a drug test (80307) and electric stimulation therapy (97014) provided on May 21, 2021, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on November 9, 2021.  You asked the Plan to pay for the dental services. You say that you are having tooth pain. You also say that these services should be covered. The Plan denied your request. The Plan says x-rays are limited to twice in 1 calendar year. The Plan also says that this benefit has been exhausted.  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 x-rays are covered, the frequency limit has been exhausted. The record shows that periapical x-rays and bitewing x-rays share a frequency limit of 2 per calendar year. The record also shows that the Plan paid for the initial periapical and the additional periapical x-ray that you received on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the bitewing x-rays (D0274) provided on November 9, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Watchman device, for the enrollee.  You asked the Plan to pre-approve the Watchman device. You say that the service is necessary. The Plan denied your request. The Plan says the enrollee's diagnosis is atrial fibrillation. The Plan states the medical record provided for review indicates the enrollee has atrial fibrillation however there is no clear intolerance to oral anticoagulation, no shared decision making, and no documented inclusion in a prospective, national, audited registry.  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 Watchman device. Our physician reviewer found there is no contraindication to anticoagulation according to the physician. As such, guidelines would not support implantation of a LAAC in this setting. In summary, LAAC placement would not be considered reasonable or medically necessary in this enrollee's clinical management. 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 Watchman device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Watchman device, for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the interrogation device evaluation provided on September 25, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the interrogation device evaluation. You say that the service was medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent. Therefore, we decided that the Plan does not have to pay for the interrogation device evaluation provided on September 25, 2021, by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 7 additional skilled nursing visits.  You asked the Plan to pre-approve 7 additional skilled nursing visits. You say that you had a stroke. You say that you have trouble checking your body for sores. You say that you have a history of bed sores that have turned septic. You also say that the visits are medically necessary. The Plan denied your request. The Plan says 7 additional skilled nursing visits are not medically necessary.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 additional skilled nursing visits. Our reviewer says that 7 additional skilled nursing visits are not medically necessary. Our physician reviewer found the provided documentation does not support that you require additional skilled nursing services to provide treatment that is medically necessary. The reviewer found that you do not require additional skilled nursing services to effectively provide treatment, care, and/or services in order to improve your condition, perform a maintenance program to maintain your condition and/or prevent deterioration. The reviewer found that you have been medically stable without any recent exacerbations of chronic medical problems or hospitalizations. Therefore, the reviewer found that the requested additional skilled nursing visits 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 additional skilled nursing visits have not been met. Specifically, the file shows that you do not have any skilled needs. Therefore, we decided that the Plan does not have to pre-approve 7 additional skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the testing services coded as 95957-26, 95908-26, 95937-26 x4 and 95885-26 x2 provided on July 22, 2020.  You asked the Plan to pay for the testing services. You say that the medical documentation supports the services as billed. The Plan denied your request. The Plan says the documentation does not support the codes 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 the billed codes is as follows: 95957 -  Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis)  95908 -  Nerve conduction studies; 3-4 studies  95937 -  Neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method  95885 -  Needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (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 testing services. Our reviewer says that the documentation does not support the services as billed. Our reviewer found the following:  CPT 95957 - Procedure report does not include documentation of a digital analysis of EEG.  Was unable to cite report as this procedure was not documented. CPT 95908 - Procedure report describes "Pedicle Screw Stimulation", nerve conduction studies should not be reported for this procedure, as nerve conduction studies measure amplitude and latency/velocity. CPT 95937 - Procedure report describes TO4, Neuromuscular Junction testing is an incorrect code to report for this procedure.  There is no code to report for TO4, as this is included in the primary neuromonitoring codes. CPT 95885 - This procedure is done with nerve conduction studies per CPT code description.  As nerve conduction studies cannot be verified by the procedure report this code 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 testing services have not been met. Therefore, we decided that the Plan does not have to pay for the testing services coded as 95957-26, 95908-26, 95937-26 x4 and 95885-26 x2 provided on July 22, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the wheelchair (K0823), component accessories (K0108), armrest (E0973), battery (E2365), and swing away manual (E1028).  You asked the Plan to pre-approve the wheelchair and accessories. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.  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.   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 wheelchair and accessories. Our reviewer says that the service is not medically necessary. Our physician reviewer found the documentation does not support that you have a mobility deficit that impairs MRADLs in the home and this mobility limitation is not ameliorated by a walker, cane, manual wheelchair and are able to use a walker in the home or a cane for MRADLs and to move room to room. Additionally, the documentation does not reveal that the requested wheelchair will significantly improve your ability to participate in MRADLs nor does it indicate the wheelchair will be used in the home.   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 wheelchair and accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve the wheelchair (K0823), component accessories (K0108), armrest (E0973), battery (E2365), and swing away manual (E1028).