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

We decided that the Plan does not have to pay for the laboratory services (87150 and 87324) provided on July 23, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the submitted claim form indicates the specimen was obtained in a laboratory setting but the record indicates it was obtained in an office setting.
The Plan must follow Medicare rules. Medicare rules say that 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 laboratory services have not been met. Specifically, the claim was submitted with a laboratory Place of Service code while the record indicates 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 laboratory services (87150 and 87324) provided on July 23, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on review of the available records, you do not meet the CMS coverage criteria for an admission to an SNF. Admission to SNF is not reasonable and not medically necessary. At the current level of function, you do not require daily skilled therapies in an inpatient setting. Documentation does not support the need for an admission to an SNF. 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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid, digital, binaural, BTE (V5267) purchased January 28, 2021.
You asked the Plan to pay for the hearing aids. You say that please reconsider your request to be reimbursed $1,000 according to your benefit package. The Plan denied your request. The Plan says enrollee's must receive their hearing services from an in-network 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 contract says you may receive hearing services from any network hearing or hearing aid provider. We looked at the file and the Plan's rules. 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 pay for the hearing aid, digital, binaural, BTE (V5267) purchased January 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for pleural drainage provided on March 19, 2021.

You asked the Plan to pay for pleural drainage, percutaneous, with insertion of indwelling catheter; with imaging guidance (32557-50). You say that the Plan should pay this claim. The Plan denied your request. The Plan says the medical record supports a more appropriate unilateral modifier for the procedure performed.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -50 modifier if the service billed with the modifier indicates a bilateral procedure.

The medical records provided do not show that the service billed with the -50 modifier was a bilateral procedure performed on both sides of the body. The documentation supports a left upper and lower chest tube placement. Specifically, it is inappropriate to report when performed on different areas of same side of body. This claim cannot be paid as submitted. Therefore, we decided that the Plan does not have to pay for pleural drainage provided on March 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to further pay for the core buildup (D2950) and retreatment of previous root canal therapy (D3347) provided March 3, 2021, by an out-of-network (OON) provider.
You asked the Plan to further pay for the core buildup and retreatment of previous root canal therapy. You say that you would like to be reimbursed for these services. The Plan denied your request. The Plan says the core buildup is not covered and the Plan has met its contractual obligation for the services rendered by an OON provider.
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 core buildup services are not among those covered under this benefit. In addition, you are being correctly charged for the retreatment of previous root canal therapy. The Plan has paid the Medicare allowed amount and you are subject to any amount greater than the payment made by the Plan.Therefore, we decided that the Plan does not have to further pay for the core buildup (D2950) and retreatment of previous root canal therapy (D3347) provided March 3, 2021, by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.

You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.

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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You are ambulating more than 100 feet and tending to activities of daily living (ADLs) with minimal supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. At this point, your care needs, as a practical matter, can be provided at a lower level of care. 

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 care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the denture relining you received on April 19, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered benefit.
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 services are not among those covered under this benefit. The Plan covers only those dental services listed in the Evidence of Coverage. Denture relining is not listed, and therefore is not covered. Therefore, we decided that the Plan does not have to pay for the denture relining you received on April 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to preapprove a pneumatic compression device (E0676).
You asked the Plan to preapprove a pneumatic compression device. You say that you require the device. The Plan denied your request. The Plan says the pneumatic compression device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to preapprove a pneumatic compression device (E0676).
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 the SNF services. You say that the services are medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.
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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the records show that the beneficiary does not require skilled nursing or therapy services on a daily 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services provided on January 13, 2021, billed with code 99232.
You asked the Plan to pay for the inpatient EM services. You say that this diagnosis code is listed as payable by Medicare. The Plan denied your request. The Plan says the diagnosis code reported as primary is not an appropriate primary diagnosis.
The Plan must follow Medicare rules. Medicare rules say that some codes are manifestation codes and should be reported after the code for the etiology of the condition. In this case, diagnosis code F05 is defined as "Delirium due to known physiological condition". It has a Code First note indicating that the underlying physiological condition should be reported first. As such, we find that the use of F05 as the primary diagnosis code is not supported. Therefore, we decided that the Plan does not have to pay for the inpatient evaluation and management (EM) services provided on January 13, 2021, billed with code 99232.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the cardiac surgery services provided on December 11, 2020, billed with codes 92929-RC and 92929-LC.

You asked the Plan to pay for the surgery services as billed. You say that these services should be paid. The Plan denied your request. The Plan says payment was made for all services aside from those codes with a status indicator of "B".

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.

Code 92929 has a status indicator of "B" on the Physician Fee Schedule. This means that payment for this service is always bundled into other services provided on the date of service. Based on this information, we decided that Medicare rules for coverage of the surgery services as billed have not been met. Therefore, we decided that the Plan does not have to pay for the cardiac surgery services provided on December 11, 2020, billed with codes 92929-RC and 92929-LC.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the pneumatic compression device and appliances provided on October 27, 2020.

You asked the Plan to pay for the pneumatic compression device (E0675) and appliances (E0673). You say that the device was prescribed by the physician for use during the enrollee's surgery. The Plan denied your request. The Plan says the device is not covered by Medicare to prevent deep vein thrombosis during and/or following surgery and payment would have been include in the facility prospective payment.

The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0675) is a preventive service. 

We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.

This item is used for a preventative service and is excluded from Medicare coverage. Therefore, we decided that the Plan does not have to pay for the pneumatic compression device and appliances provided on October 27, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory service (81546) rendered by the out-of-network (OON) provider on April 30, 2021.

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

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 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 this service. Therefore, we decided that the Plan does not have to pay for the laboratory service (81546) rendered by the out-of-network (OON) provider on April 30, 2021.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pre-approve additional transportation services.
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says that you have exhausted the allowable transportation benefit for this calendar year.
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. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, our organization requested a report of the transportation services provided to you for this calendar year so that we may determine your eligibility; however, this information was not provided by the Plan. Therefore, we decided that the Plan has to pre-approve additional transportation services.
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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided on March 26, 2021,
through March 27, 2021.
You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says this claim has not been billed with the
required secondary diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that contractors shall fully reject inpatient hospital
claims for LAAC with discharges on or after February 8, 2016, when billed without the appropriate procedure,
diagnosis, or clinical trial codes.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the inpatient hospital services have not been met. Specifically, this claim has not been billed with
the required secondary diagnosis code. Therefore, we decided that the Plan does not have to pay for the
inpatient hospital services provided on March 26, 2021, through March 27, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
You asked the Plan to pre-approve the MRI. You say that the records provided support the need for the requested MRI. The Plan denied your request. The Plan says there is no record that the enrollee had contact with her doctor after a recent six-week trial of treatment that failed to improve her symptoms.
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is not medically necessary. Our physician reviewer found the enrollee has hip and back pain and right lower extremity weakness. This has developed over the past six months, although she had similar complaints in 2017-2019. At that time, an MRI showed diffuse L-S degenerative changes without central stenosis but with Left foraminal stenosis at L3-4. She was referred to Neurosurgery who recommended exercise (swimming and walking) which she may or may not have done. Around that same time, she was seen by physical therapy and given a home exercise program. She was evaluated by her primary care provider last month, who found mild-moderate left lower extremity weakness without deep tendon reflex changes or rheumatoid factor symptoms. Her primary care provider ordered a repeat MRI, along with a recommendation to begin a regular exercise program. In this case the enrollee has not completed a course of conservative therapy. 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 MRI have not been met.
Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit, extraspinal manipulation, and imaging services provided by a chiropractor from March 16, 2021, to March 30, 2021.
You asked the Plan to pay for chiropractic services. You say that you were informed that these services are covered with a 20% coinsurance. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor. The Plan also says that they have approved coverage for the chiropractic spinal manipulation services, so this denial is only for the services other than manual manipulation of the spine.
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 services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an office visit, extraspinal manipulation, and imaging services provided by a chiropractor from March 16, 2021, to March 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services coded with 99223 provided January 16, 2021.
You asked the Plan to pay for the medical services coded with 99223. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the procedure coded 99223 is not supported by the medical records as 99221 would be more appropriate in this scenario.
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 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: 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 problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit. 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 coded with 99223. Our reviewer says that the medical records do not support the services as billed. Our reviewer found the review has determined that the original billed CPT code 99223, is not supported by the medical documentation submitted. Medical records are still needed to support the service 99223. The records do not support the claim as billed in this case. 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 coded with 99223 have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded with 99223 provided January 16, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the transthoracic echocardiography (93306) rendered by the out-of-network (OON) provider on November 13, 2020.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.
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 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
this service. Therefore, we decided that the Plan does not have to pay for the transthoracic echocardiography
(93306) rendered by the out-of-network (OON) provider on November 13, 2020.