Persius/hicric huggingface dataset:
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 97162) provided on July 5, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the submitted code does not appropriately reflect the services provided by the PTA.
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 97162 is "Physical therapy evaluation: moderate complexity, requiring these components: A history of present problem with 1-2 personal factors and/or comorbidities that impact the plan of care; An examination of body systems using standardized tests and measures in addressing a total of 3 or more elements from any of the following: body structures and functions, activity limitations, and/or participation restrictions; An evolving clinical presentation with changing characteristics; and Clinical decision making of moderate complexity using standardized patient assessment instrument and/or measurable assessment of functional outcome. Typically, 30 minutes are spent face-to-face with the patient and/or family". We asked our coding 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 services. Our reviewer says that the use of CPT 97162 is not supported by the records provided. Our coding reviewer found that CPT 97162 was performed by a Physical Therapy Assistant (PTA) July 5, 2019. Per the code description, there is "Clinical decision making of moderate complexity", which does not fall within the scope of a Physical Therapy Assistant. Per the American Physical Therapy Association, "In summary, PTs must examine, evaluate, screen, diagnose, determine a prognosis, develop plans of care, oversee documentation and care, and discharge patients. PTAs are highly trained in providing treatment interventions for patients and are an asset for patient care, especially when the PT and PTA have a mutually trusting and respectful relationship." 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 the services (CPT 97162) provided on July 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided on January 16, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
medically necessary.
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 pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found that the enrollee is a 28-year-old female with a history of pelvic pain. She underwent an S2-S3 bilateral
nerve block on January 16, 2020. The procedure was performed using monitored anesthesia care (MAC). Per
the Guidelines from the American Society of Anesthesiologists and the International Spine Intervention
Society, minor pain procedures, under most routine circumstances, do not require anesthesia care other than
local anesthesia. The review has determined that the requested anesthesia services were not medically
reasonable or necessary 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 the services have not been met. Therefore, we decided that the Plan does not
have to pay for the anesthesia services provided on January 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided from June 28, 2019 to July 3,
2019.
You asked the Plan to pay for inpatient stay. You say that the managing physician was of the opinion that these
services were medically necessary. The Plan denied your request. The Plan says the denial of payment for these
services is correct, because the enrollee was stable for transfer to an in-network hospital prior to admission.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for
necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider,
approval is required.
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 inpatient stay. Our reviewer says that the
inpatient hospital stay does not meet the Medicare criteria for coverage. Our physician reviewer found the
enrollee was stabilized in the emergency department and could have been considered for transfer to an
approved facility. Alternatively, approval could have been sought to admit the enrollee to the same hospital but
a request for approval was not initiated as required by the 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 inpatient stay have not been met. Therefore, we decided that the Plan does not
have to pay for inpatient hospital care provided from June 28, 2019 to July 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on November 19, 2019.
You asked the Plan to pay for the office visit. The Plan denied your request.
The Plan must follow Medicare rules. Medicare rules say that claim lines that have been determined to be exact
duplicates of another claim are denied.
We find that the office visit was billed and paid for by the Plan. Because the office visit has already been billed
and paid, the service at issue cannot be paid again. Therefore, we decided that the Plan does not have to pay for
the office visit provided on November 19, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee on July 23, 2019.
You asked the Plan to pay for the services. You say that the claim was processed correctly per how the provider billed for the services. The Plan denied your request. The Plan says the services were not billed correctly.
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 denied codes is: CPT 92929: Percutaneous transcatheter placement of intracoronary stent(s), with coronary angioplasty when performed; each additional branch of a major coronary artery (List separately in addition to code for primary procedure) CPT 92941: Percutaneous transluminal revascularization of acute total/subtotal occlusion during acute myocardial infarction, coronary artery or coronary artery bypass graft, any combination of intracoronary stent, atherectomy and angioplasty, including aspiration thrombectomy when performed, single vessel We asked our coding 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 services. Our reviewer says that the services at issue in this case were not coded and not supported by the medical records. Our coding reviewer found CPT 92929 and CPT 92941 are bundled with procedure 93458 which was performed on July 23, 2019 and was paid by the health plan. Per the NCCI bundling guidance, a modifier is allowed to unbundle this code as a separately identifiable procedure, providing the medical record supports the use of such modifier. However, the claim was submitted to the health plan without the use of a modifier to identify this procedure as a separately identifiable procedure, therefore, this service is not eligible for reimbursement based on the way it was billed.
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 inpatient hospital services provided to the enrollee on July 23, 2019.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiation therapy.
You asked the Plan to pre-approve radiation therapy. 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 follows Medicare rules. Medicare rules say that IMRT is covered when specific criteria is met. 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 radiation therapy. Our reviewer says that the services are not medically necessary. Our physician reviewer found IMRT is unfavorable due to lack of demonstration of need, and not being standard to routinely use IMRT (i.e., not Consistent with standards of good medical practice). We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiation therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve radiation therapy.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the Laryngoscopy (31575) provided on
January 30, 2020.
You asked the Plan to adjust the copayment. You say that you are requesting a reconsideration of the Plan's
denial. The Plan denied your request. The Plan says the cost sharing has been applied correctly to the service
provided.
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 $350
copayment for in-network outpatient hospital surgery.
You have been asked to pay a $175.34 copayment for the in-network outpatient hospital surgery provided. This
copayment is the Medicare allowed amount for this service, which is less than the $350 applicable copayment.
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 adjust the copayment for the Laryngoscopy (31575) provided on January 30, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve respite care (S9122) provided on October 31, 2019.
You asked the Plan to pre-approve respite care. You say that this should be covered. The Plan denied your request. The Plan says you exceeded the maximum benefit for 2019.
Medicare generally does not cover custodial care. However, the Plan offers respite care benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers up to 40 hours of respite care per calendar year. We looked at the file and the Plan's rules. The records show that you met the 40-hour yearly benefit limit for 2019 prior to the date of service at issue. Based on this information, we decided that the Plan's rules for coverage of respite care have not been met. Therefore, we decided that the Plan does not have to pre-approve respite care (S9122) provided on October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided on November 6, 2019 by an out of network (OON) provider.
You asked the Plan to pay for physician services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that the member's primary care physician did not refer these 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 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 has network providers available who can provide 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 physician services provided on November 6, 2019 by an out of network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 99285) provided on December 4, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is 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 99285 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function". We asked our coding 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 services. Our reviewer says that the use of CPT code 99285 is not supported by the records provided. Our coding reviewer found that the medical records provided do not include documentation to validate that an "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function" was performed on December 4, 2019, therefore this service cannot be verified and is not eligible for reimbursement.
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 the services (CPT 99285) provided on December 4, 2019.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services.
You asked the Plan to pay for the ambulance services. You say that you want to appeal the Plan's denial of the services. You stated that you were unaware the Plan would not pay for the EMS charges if you did not receive oxygen. You say that you were not advised of the requirements needed for the Plan to pay for the services. The Plan denied your request. The Plan says these services are not a covered benefit.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on January 29, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a lumbar/sacral facet joint block lower back injection (64493).
You asked the Plan to pre-approve a lumbar/sacral facet joint block lower back injection. 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 follows Medicare rules. Medicare rules say that facet joint blocks will be considered reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) suspected to originate from the facet joint. 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 lumbar/sacral facet joint block lower back injection. Our reviewer says that the services are not medically necessary. Our physician reviewer found the medical records submitted do not document lumbar disease. The provided medical records only document cervical region disease. Therefore based upon the submitted records, the requested 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 a lumbar/sacral facet joint block lower back injection have not been met. Therefore, we decided that the Plan does not have to pre-approve a lumbar/sacral facet joint block lower back injection (64493).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radiofrequency ablation of the nerves innervating the sacroiliac (SI) joint (64640).
You asked the Plan to pre-approve radiofrequency ablation of the nerves innervating the SI joint. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria has not been met.
The Plan follows Medicare rules. Medicare rules say that prior to blockade, all patients with pain complaints require an evaluation that includes, at a minimum, an assessment of the source of the pain and treatment of any underlying pathology. 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 radiofrequency ablation of the nerves innervating the SI joint. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review has determined that you do not meet the coverage criteria. The requested radiofrequency ablation of the sacroiliac (SI) joint is not medically necessary or reasonable. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of radiofrequency ablation of the nerves innervating the SI joint have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation of the nerves innervating the sacroiliac (SI) joint (64640).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Advair Hfa Aer 230/21.
You asked the Plan to pre-approve Advair Hfa Aer 230/21. You say that the requested medication is necessary. The Plan denied your request. The Plan says the enrollee's plan does not have a Medicare Part D benefit or a separate pharmacy benefit managed by the plan, therefore self-administered drugs do not meet the criteria for 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 Advair Hfa Aer 230/21.
Benefits for Advair Hfa Aer 230/21 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: Other
Decision: Unfavorable

We decided that the Plan does not have to pay for the respite care rendered on October 17, 2019.
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 you exceeded the benefit limit.
The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. The Plan covers 40 hours of respite care per calendar year. Review of the file shows that you were approved for 40 hours of respite care on August 12, 2019. You exhausted the 40 hour limit per calendar year as of October 17, 2019. Based on this information, we decided that Plan's rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the respite care rendered on October 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient care provided from October 26, 2019, to October 29, 2019.
You asked the Plan to pay for the inpatient care. The Plan denied your request. The Plan says the enrollee was stabilized at the time of admission.
The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.
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 inpatient care. Our reviewer says that the requested inpatient care was not medically reasonable and necessary. Our physician reviewer found that the enrollee was declared stable for transfer at the time of hospitalization. The hospitalist made no further declarations of stability/instability for transfer throughout the hospitalization. Any care provided after the decision to admit the enrollee is post-stabilization care and is not covered unless pre-authorized 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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient care provided from October 26, 2019, to October 29, 2019.