Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided May 21, 2019 to May 23, 2019.
You asked the Plan to pay for the acute inpatient hospital care. You say that this admission was warranted and supported by the clinical documentation in the medical record. The Plan denied your request. The Plan says that the treatment documented does not meet InterQual criteria for an inpatient admission.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the review indicates that the enrollee was a then, 66 year old obese male who presented to the Emergency Department on May 21, 2019 with complaints of chest burning sensation and hyperglycemia. He checked his blood sugar and it showed an elevated result of 400. His medical history was significant for Coronary artery disease, diabetes mellitus type II, and hypertension. His past surgical history included a Coronary artery bypass graft. His electrocardiogram displayed atrial premature complex and left bundle branch block. He was admitted for chest pain and hyperglycemia. He was treated with IV heparin infusion, aspirin and insulin injection. His condition stabilized and improved and he was discharged home with outpatient follow-up on May 23, 2019. The review has determined that the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided May 21, 2019 to May 23, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided July 16, 2019 to July 20,2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says that services could have been provided on an outpatient basis.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided July 16, 2019 to July 20,2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that the requested service is necessary to determine the cause of your pain. 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. 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 an MRI of the lumbar spine. Our reviewer says that the service is not medically necessary. Our physician reviewer found based on the medical records provided the lumbar spine MRI is not medically reasonable and 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 an MRI of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lumbar spine (72148).
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided August 9, 2019 to August 14,
2019.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary.
The Plan denied your request. The Plan says that services could have been provided on an outpatient basis.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases,
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or
more.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer
says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician
reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably
expected that the patient's necessary hospital care (including earlier ED and/or observation care) would span
two midnights.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of acute inpatient hospital care have been met. Therefore, we decided that the Plan
has to pay for the acute inpatient hospital care provided August 9, 2019 to August 14, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for the Hydrotherapy Walk-in Bathtub
You asked the Plan to reimburse you for the walk-in bathtub. You say that you were receiving aquatic therapy with therapeutic exercises but after moving it was not available. The Plan denied your request. The Plan says Medicare does not provide coverage for equipment that does not primarily and customarily serve a medical purpose or is useful to a person in the absence of illness or injury.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. A walk-in bathtub is not considered to be durable medical equipment per Medicare Guidelines. Therefore, we decided that the Plan does not have to reimburse you for the Hydrotherapy Walk-in Bathtub
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided by provider on September 6, 2019.You asked the Plan to pay for the knee orthoses (L1851) and suspension sleeves (L2397). You say that the orthoses were medically necessary.The Plan denied your request. The Plan says the evaluation did not take place at a qualifying originating site.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 knee orthoses (L1851) and suspension sleeves (L2397). Our reviewer says that the orthoses were not medically necessary. Our physician reviewer found the enrollee's chief complaints were right knee pain and left knee pain, documented in 2 separate notes on the same date of service. The documentation in the case file does not support that the requested knee orthoses with sleeves were medically reasonable and necessary for the enrollee in this case, according to the coverage criteria established by the LCD. There is no documentation of recent injury to, or recent surgical procedure on, either of the enrollee's knees, and there is insufficient credible objective documentation of joint laxity. The item coded L2397 (sleeve) is not separately payable when the base item is not covered.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 knee orthoses (L1851) and suspension sleeves (L2397) have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthoses and suspension sleeves provided by provider on September 6, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology (88172 and 88173) provided on August 2, 2019.You asked the Plan to pay for the cytopathology. You say that you would like reconsideration as thisclaim was denied in error. The Plan denied your request. The Plan says CPT codes 88172 and 88173 have been denied as duplicate claim lines.The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined to beexact duplicates of another claim or claim line are denied.We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the cytopathology have not been met. Specifically, the claim has been submitted without an appropriate modifier to indicate that these are separate, distinct procedures from those that have been previously processed and paid. Therefore, we decided that the Plan does not have to pay for cytopathology (88172 and 88173) provided on August 2, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services rendered to the enrollee on June 18, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 63048 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 63048 is laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure).We find that CPT code 63048 is not supported in the medical record. Specifically, code 63048 is an add-on code and given that the primary procedure code was not supported, the add-on code is also not supported. 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 forthe services rendered to the enrollee on June 18, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing rendered to the enrollee on October 3, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says there is no valid physician order.The Plan must follow Medicare rules. Medicare rules say that laboratory services must be ordered by a physician.We looked at the file and Medicare rules. There is no valid physician order in the submitted documentation. 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 forthe drug testing rendered to the enrollee on October 3, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for CPT codes 76705, 99215, and 00910 provided on April 2, 2019 and April 3, 2019.
You asked the Plan to pay for CPT codes 76705, 99215, and 00910. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Medicare says in order to determine medical necessity that pertains directly to the enrollee and their specific clinical scenario, medical records are required. In this case, there were no medical records documenting that an ultrasound and an evaluation was performed on April 2, 2019 and April 3, 2019. Furthermore, Medicare says that when anesthesia services are performed, physicians must report the appropriate anesthesia modifier to denote whether the service was personally performed, medically directed, or medically supervised. The file shows the claim was submitted without an appropriate anesthesia
modifier. Therefore, we decided that the Plan does not have to pay for CPT codes 76705, 99215, and 00910 provided on April 2, 2019 and April 3, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided on October 4, 2019 by an out of network (OON) provider.You asked the Plan to pay for an office visit. You say that our clinical documentation is clear and demonstrates medical necessity.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 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 an office visit provided on October 4, 2019 by an out of network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Armour Thyroid for enrollee.You asked the Plan to pre-approve Armour Thyroid. The Plan denied your request. The Plan says drug coverage is limited to Medicare Part B covered drugs.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 Armour Thyroid for enrollee. Benefits for Armour Thyroid 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: Imaging
Decision: Favorable

We decided that the Plan has to pre-approve an MRI of the left forearm/wrist.You asked the Plan to pre-approve the MRI. You say that the enrollee requires this imaging to ascertain the status of the nerves in her arm.The Plan denied your request. The Plan says that the member has not had appropriate physical therapy which should be tried before imaging is needed.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 imaging is considered medically reasonable and necessary in this case. Our physician reviewer found this enrollee presents with a 3-month history of severe left wrist pain with movement and paresthesias. Significant functional limitations are noted in activities of daily living. Clinical exam findings and lab studies suggest the potential for inflammatory flexor tenosynovitis. Additionally, there is electrodiagnostic evidence of median and radial nerve compression in the forearm. The enrollee has failed to improve with over 3 months of reasonable and/or comprehensive conservative treatment, including activity modification, splinting, oral steroids, and oral NSAIDs. The treating physician has requested MRI of the left forearm with and without IV contrast to evaluate for an inflammatory process or mass lesion causing nerve compression in the forearm. Current evidence based medical guidelines would support MRI as the next step for diagnosis and treatment planning. Therefore, this request for left forearm/wrist is medically reasonable and necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have been met.Therefore, we decided that the Plan has to pre-approve an MRI of the left forearm/wrist.If the Plan does not agree with our decision,they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician's services provided on May 8, 2019, May 15, 2019,
July 23, 2019 and July 30, 2019.
You asked the Plan to pay for the physician's services. The Plan denied your request. The Plan says you must
receive care from in-network providers with the exception of emergency or urgent care, dialysis while
temporarily out of the plan's service area or if the care cannot be provided with an in-network provider, which
requires prior authorization from the plan.
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
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for physician's services provided on May 8, 2019, May 15, 2019,
July 23, 2019 and July 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 9, 2019 to enrollee by an out of network (OON) provider.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 the services were 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 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 forthe medical services provided on August 9, 2019 to enrollee by an out of network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve core buildup for tooth #12.You asked the Plan to pre-approve these services. You say that you disagree with the denial.The Plan denied your request. The Plan says the services are not covered.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 among those covered under this benefit.Therefore, we decided that the Plan does not have to pre-approve core buildup for tooth #12
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services renderedJuly 18, 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 procedure code 99354 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 99354 is prolonged office or other outpatient service first hour (List separately in addition to code for office or other outpatient Evaluation and Management or psychotherapy service). We find that CPT code 99354 is not supported in the medical record. Specifically, the documentation does not support that prolonged service in the office or other outpatient setting beyond the first hour was performed for the date of service at issue. 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 services
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay fordrug testing provided on November 1, 2019.You asked the Plan to pay fordrug tests. You say that you have submitted a valid physician laboratory requisition form.The Plan denied your request. The Plan says the denial of payment for this service is correct, because there is no established relationship between the enrollee and this ordering provider.The Plan must follow Medicare rules. Medicare rules say that a physician order or clear intent to order specific lab services is required for covered lab services. We looked at the file and Medicare rules. The documentation submitted does not include a valid physician order or clear intent to order the specific lab service billed on this claim. Based on this information, we decided that Medicare rules for coverage of drug tests have not been met.Therefore, wedecided that the Plan does not have to pay fordrug testing provided on November 1, 2019.