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

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve the SNF services. You say that SNF services are medically necessary The Plan denied your request. The Plan says SNF services are 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 the SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs at this point are custodial and, as a practical matter, can be provided at a lower level of care (ex. home, assisted living, long term 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the
enrollee.
You asked the Plan to pre-approve the LTACH services. You say that these services are medically necessary.
The Plan denied your request. The Plan says that the member can remain in the current acute care location until
such time no further acute level care is needed.
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. As acute care
hospitals and LTACHs are licensed to provide the same level of care, there is no advantage in moving the
member from the current acute care hospital to a LTACH. There is no documentation provided necessitating
admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The
enrollee does not require services at the LTACH that are not available at the acute care hospital where he is
currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare
criteria for LTACH services.
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 for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for infusion services (96361) provided on November 11, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for OON infusion services. You say that this is supported in the records. The Plan denied your request. The Plan says this was was not authorized.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for infusion services (96361) provided on November 11, 2020 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the durable medical equipment (DME) defined by codes A7039 and A7030 with the date of service January 13, 2021.
You asked the Plan to pay for the DME. You say that the claim should be paid. The Plan denied your request. The Plan says the documentation does not indicate services are necessary for treatment of the enrollee's condition.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when the patient's medical record contains sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use.
The record shows that documentation submitted did not indicate the provider discussed the need for the billed supply code, so the billed supply code cannot be verified. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) defined by codes A7039 and A7030 with the date of service January 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent nursing facility care services provided on February 4, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the subsequent nursing facility care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
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 the subsequent nursing facility care services provided on February 4, 2021 by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services from January 24, 2021, through February 22, 2021.
You asked the Plan to pay for the SNF services. The Plan denied your request. The Plan says based upon
Medicare coverage guidelines; medical necessity cannot be established for continued stay at the skilled nursing
facility.
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 pay for the SNF services. Our reviewer says that
daily skilled services are not medically necessary. Our physician reviewer found based on the medical records
provided there is no documentation that the enrollee required skilled nursing services, i.e., the specialized skill,
knowledge and judgment of a skilled professional nurse were not required to safely and effectively provide
medically necessary and reasonable treatment. The enrollee did require skilled therapy services, i.e., the
specialized skill, knowledge and judgment of a qualified therapist were required to safely and effectively
provide medically necessary and reasonable treatment. Daily skilled services were not required. The enrollee
did not require the services on an inpatient basis, only in a skilled nursing facility setting. Services in the
nursing facility appear custodial in this case from January 24, 2021, through February 22, 2021.
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 pay for continuation of SNF services provided from January 24, 2021, through February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a semi-electric hospital bed (E0260) and manual wheelchair (K0001).
You asked the Plan to pre-approve the hospital bed and wheelchair. You say that these services are necessary, and you were told these services would be available to you. The Plan denied your request. The Plan says these services are not medically necessary.
The Plan must follow Medicare rules. According to Medicare, a semi-electric hospital bed is medically necessary when an enrollee's condition must require frequent changes in body position and/or there may be an immediate need for a change in body position and the patient can operate the controls and cause the adjustments. Exceptions may be made to this last requirement in cases of spinal cord injury and brain damaged patients.
According to Medicare, a manual wheelchair can be medically necessary when the enrollee has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living such as toileting, feeding, dressing, grooming and bathing in customary locations in the home. The enrollee's home must provide adequate access for maneuvering a manual wheelchair and the enrollee's mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.
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 hospital bed and wheelchair. Our reviewer says that the requested items/services are not medically reasonable and necessary. Our physician reviewer found that in this case, the documentation does not support that you are unable to accomplish bed mobility, ambulation and self-care tasks with the use of a walker. The requested equipment is not medically necessary for mobility or mobility-related activities of daily living.
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 hospital bed and wheelchair have not been met. Therefore, we decided that
the Plan does not have to pre-approve a semi-electric hospital bed (E0260) and manual wheelchair (K0001).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. 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 LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided necessitating admission to a LTACH. The enrollee does not require services at the LTACH that are not available at the acute care hospital where they are currently receiving care. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve LTACH services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (0031U, 0032U, 81227, 81240, 81241,
81291, 81355, 81401,81225, 81226, 81479, 81230, 81231, 81328) provided on September 16, 2020.
You asked the Plan to pay for laboratory services. You say that this is supported in the records. The Plan
denied your request. The Plan says this was billed with an incorrect POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place
where the sample was taken is reported as the Place of Service (POS).
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we
decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that
the Plan does not have to pay for laboratory services (0031U, 0032U, 81227, 81240, 81241, 81291, 81355,
81401,81225, 81226, 81479, 81230, 81231, 81328) provided on September 16, 2020.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for initial nursing facility care provided on December 16, 2020.
You asked the Plan to pay for the initial nursing facility care. You say that the physician only provided medically necessary services to the member in good faith, and the rendered services meet professionally recognized standards of healthcare. The Plan denied your request. The Plan says that the facility received Medicare part-A skilled nursing facility payment and is responsible to provide all services and to pay any and all vendors.
The Plan must follow Medicare rules. Medicare rules say that physician's professional services and services of certain non-physician providers are excluded from Part A Prospective Payment System (PPS) payment and the requirement for consolidated billing and must be billed separately by the practitioner. We looked at the file and Medicare rules. Medicare says that physician services are not included in Part A PPS payments. Based on this information, we decided that Medicare rules for coverage of the initial nursing facility care have been met. Therefore, we decided that the Plan has to pay for initial nursing facility care provided on December 16, 2020.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (87486, 87541, 87581, 87640, 87798) provided on May 5, 2020.
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with the correct POS.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (87486, 87541, 87581, 87640, 87798) provided on May 5, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten additional home health skilled nursing visits.
You asked the Plan to pre-approve additional home health skilled nursing visits. You say that services are medically necessary. The Plan denied your request. The Plan says the wounds are superficial and would not require a skilled nurse.
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 additional home health skilled nursing visits. Our reviewer says that the service is not medically necessary. Our physician reviewer found that the enrollee does not appear to be homebound, as she has been attending office appointments. The extent of the enrollee's wounds is unclear. The type and frequency of wound care required is unclear. Skilled nursing needs are not documented. As such, the requested home health registered nurse services are not shown to be 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 additional home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten additional home health skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on December 22, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples
(e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on December 22, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the needle electromyography services coded 95886 and the
sterile needles coded A4215 provided on November 13, 2020.
You asked the Plan to pay for the needle electromyography services and the sterile needles. You say that you
would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not
payable 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 A4215 is needle, sterile, any size, each.
We find that CPT code A4215 is not supported in the medical record. Specifically, separate payment cannot be
made to any provider or supplier other than the facility in the prospective payment for services (PPS) furnished
to the enrollee in preparation for, during, or following a procedure or surgery. The facility must furnish all
necessary covered services/supplies to the beneficiary either directly or under arrangements made between the
facility and outside vendors. The enrollee received the services during or in preparation for a procedure or
surgery at the facility. Payment for this service would be included in the facility PPS payment. Payment for this
service is the responsibility of the facility. Based on this information, we decided that Medicare rules for
coverage of the needles billed have not been met.
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, we have confirmed that code 95886
for the needle electromyography services and the sterile needles has a bundled relationship with code 99886
and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted,
Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the
needle electromyography services coded 95886 and the sterile needles coded A4215 provided on November 13,
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on September 12, 2020.
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 procedure code 15610 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 15610 is delay of flap or sectioning of flap (division and inset); at scalp, arms, or legs. We find that CPT code 15610 is not supported in the medical record. Specifically, there is no documentation of a delay flap or sectioning of flap at the scalp, arms, or legs. Based on this information, we decided that
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on September 12, 2020.