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

We decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.You asked the Planto pre-approvethe LTACH services. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services could be provided in another setting.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 andnecessary in this case. Our physician reviewer found the enrollee is currently undergoing treatment at an ACH for sepsis attributed to pneumonia and infectious diarrhea. The enrollee has a tracheotomy and feeding tube at baseline. The enrollee was placed on a ventilator upon admission. It appears that LTACH services were requested prior to fully addressing the enrollee's acute issues and prior to attempting any ventilator weaning. The enrollee has since shown signs of clinical improvement and has been weaned from the ventilator to a tracheotomy collar. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute servicesare required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules forcoverage of the LTACH services have not been met.Therefore, we decided that the Plandoes not haveto pre-approveadmission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the revision or removal of peripheral or gastric neurostimulator pulse generator (64595) provided on July 22, 2019.You asked the Plan to pay for the revision or removal of peripheral or gastric neurostimulator pulse generator. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a device code is required with the dependent procedure.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the revision or removal of peripheral or gastric neurostimulator pulse generator. Our reviewer says that 64595 does not meet criteria for billing or reimbursement consideration. Our reviewer found CMS.gov July Addendum B July 1, 2019, HCPCS code 64595 -Revision orremoval of peripheral or gastric neurostimulator pulse generator or receiver indicates 64595 is a code that requires a device code be submitted on the same claim in order to be considered for reimbursement.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forsurgical services provided to the enrollee on May 23, 2019 and billed under code 44160.You asked the Plan to pay forcode 44160. You say that this claim should be paid.The Plan denied your request. The Plan says the Medicare billing criteria are not met because procedure code 44160-22 is not supported by the medical records submitted. The Plan states the operative report did not include documentation of a partial colectomy with removal of terminal ileum and ileocolostomy for increased procedural services; therefore,this code cannot be verified.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT codeand provide medical records that support the services billed.In this case, the records provided are both limited and, in some cases, not legible. The services billed cannot be confirmed. Based on this information, we decided that Medicare rules for coverage of code 44160 have not been met.Therefore, we decided that the Plan does not have to pay forsurgical services provided to the enrollee on May 23,2019 and billed under code 44160.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forMOHS micrographic technique provided to the enrollee on July 29, 2019 and billed under code 17311.You asked the Plan to pay forthis service. You say that this claim should be paid.The Plan denied your request. The Plan says the Medicare billing criteria were not met.The Plan says that submitted did not include documentation of mapping, color coding of specimens, microscopic examination of specimens by the surgeon, and histopathologic preparation including routine stain(s) to support the code billed; therefore, the billed service cannot be verified. The Plan states that multiple attempts were made to contact the provider for additional information. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT codeand provide medical records that support the services billed. In this case, code 17311 is not supported by the medical records provided. The Plan has attempted to obtain records and/or a corrected claim. Therefore, we decided that the Plan does not have to pay forMOHS micrographic technique provided to the enrollee on July 29, 2019 and billed under code 17311.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran electrocardiogram (an EKG) (93000) provided on July 9, 2019.You asked the Plan to waive the copayment foran EKG. You say that you should not be responsible for the bill due to the fact that you went in for an annual wellness visit, which is covered once a year with no copay.The Plan denied your request. The Plan says outpatient diagnostic tests have a $20 copayment. The Plan says an EKG is considered an outpatient diagnostic test and would have a separate member cost share than an annual wellness exam. The Plan further says that other outpatient diagnostic tests include but are not limited to sleep studies, EKG's, stress tests, vascular studies, and breathing capacity tests.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 $20 copayment for outpatient diagnostic tests. You have been asked to pay a $15.96copayment for an EKG. This servicefalls within the outpatient diagnostic tests benefit category. This amount is less than the usual copayment for this service.The record shows that during your Wellness Visit you were monitored for an existing medical condition by receiving an EKG.This means that you havebeen 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 waive the copayment foran electrocardiogram (an EKG) (93000) provided on July 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a Hemiarthroplasty (27125) provided on June 20, 2019.You asked the Plan to pay for the Hemiarthroplasty. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted did not include a detailed procedure note of hemiarthroplasty, hip, partial was performed.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 27125 is Hemiarthroplasty, hip,partial (e.g., femoral stem prosthesis, bipolar arthroplasty).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 Hemiarthroplasty. Our reviewer says that CPT code 27125 does not meet criteria for billing or reimbursement consideration. Our reviewer found the records provided do not include documentation of a Hemiarthroplasty, hip, partial (e.g., femoral stem prosthesis, bipolar arthroplasty) being performed on June 20, 2019.
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 Hemiarthroplasty have not been met. Therefore, we decided that the Plan does not have to pay for a Hemiarthroplasty (27125) provided on June 20, 2019
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for heart vessel repair (33500) provided on July 15, 2019.You asked the Plan to pay for the heart vessel repair. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the medical records did not include documentation of a repair of a coronary arteriovenous or arteriocardiac chamber fistula; with cardiopulmonary bypass; therefore, this code cannot be verified.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 33500 is Repair of coronary arteriovenous or arteriocardiac chamber fistula; with cardiopulmonary bypass.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 heart vessel repair. Our reviewer says that CPT code 33500 is not supported by the medical record. Our reviewer found the record does not contain evidence that a coronary fistula was repaired during this episode of care.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 heart vessel repair have not been met. Therefore, we decided that the Plan does not have to pay for heart vessel repair (33500) provided on July 15, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forarthrodesis (22612 and 22558) a laminectomy (63047) provided on May 9, 2019.You asked the Plan to pay for the arthrodesis and laminectomy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plansays these services are not supported in the medical records that were submitted.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 22612 is arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed).The CPT Code Manual definition of code 22558 is arthrodesis, anterior interbody technique, including minimal discectomy to prepare interspace (other than for decompression); lumbar.The CPT Code Manual definition of code 63047 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; lumbar.
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 arthrodesis and laminectomy. Our reviewer says that CPT codes 22612 and 63047 are not supported as separately reportable. According to CPT rules, there is a more specific code for an arthrodesis, posterior or posterolateral, including laminectomy and/or discectomy when performed at the same disc space. Our reviewer found CPT code 22558 is not supported. The record does not contain evidence that lumbar arthrodesis was performed by an anterior approach.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 arthrodesis and laminectomy have not been met. Therefore, we decided that the Plan does not have to pay for arthrodesis (22612 and 22558) a laminectomy (63047) provided on May 9, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a Thoracoscopy (32651) provided on June 2, 2018You asked the Plan to pay for the Thoracoscopy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not indicate that a thoracoscopy, surgical; with control of traumatic hemorrhage was performed.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 32651 is Thoracoscopy, surgical; with partial pulmonary decortication.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 Thoracoscopy. Our reviewer says that CPT code 32651 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of a Thoracoscopy, surgical; with partial pulmonary decortication. Therefore, the service cannot be verified.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for testing (95999).You asked the Plan to pay for the testing. You say that you would likereconsideration based on the records submitted. The Plan denied your request. The Plan says it considered a bundled procedure and payment for it is included in payment for the already-approved neuromonitoring.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the Train of Four testing. Our reviewer says that records indicate that testing is indicated for unlisted CPT code 95999. Our reviewer found According to CPT rules, testing is included in other intraoperative neuromonitoring procedures and is not separately reportable.We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for testing (95999).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance forinjection services (64491, 64490, 77003, 64492) provided from July 31, 2017 through March 20, 2019.You asked the Plan to waive the coinsurance forinjection services. You say that the provider did not bill you in a timely manner and you were not aware of having a 20% coinsurance for drugs. You also say that this bill will cause you financial hardship to pay.The Plan denied your request. The Plan says Medicare Part B prescription drugs have a 20% coinsurance. The Plan also says these drugs aren't self-administered by the patient and are injected or infused by a physician.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 20% coinsurance for Medicare Part B prescription drugs. You have been asked to pay a 20% coinsurance for injection services. Theseservices fall within the Medicare Part B prescription drugs benefit category. Each date of service is $174 x 20% = $34.80 (11 dates of service x $34.80 = $382.80). 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 waive the coinsurance forinjection services (64491, 64490, 77003, 64492) provided from July 31, 2017 through March 20, 2019
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. The Plan denied your request. The Plan says records do not indicate that the criteria for coverage have been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requestedIRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee's prior level of function was living with his spouse and being independent with mobility with a hemi-walker and activities of daily living. Our physician reviewer found that the enrollee's primary care physician notes from January 3, 2020 states "no new problems, feels well". Our physician reviewer found that there are no therapy evaluations from physical therapy or occupational therapy. Our physician reviewer found that the enrollee's current level of function is not documented. Our physician reviewer found that the enrollee does not meet criteria for coverage of IRF. Our physician reviewer found that the enrollee is currently medically stable and there is no evidence of complex medical issues that require monitoring by an inpatient rehabilitation physician three times per week or acute rehab nursing care. Our physician reviewer found that, while the enrollee may benefit fromphysical therapy and occupational therapy, there is no evidence of a need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation 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 IRF care have not been met.Therefore, we decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.You asked the Planto pre-approvethe LTACH services. You say that theenrollee clearly requires long term acute care which is best provided in an LTACH facility.The Plandenied your request. The Plansaysthe enrollee can receive this care in the current facility.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 the patient is currently undergoing treatment at an ACH for respiratory failure in the setting of airway stenosis. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee was decannulated, but had to be re-intubated and a tracheotomy placed. The enrollee has again been weaned from the ventilator and is tolerating a tracheotomy mask. It is unclear if decannulation is to be again attempted. As LTACHs and ACHs are licensed to provide the same level of care, there is no advantage in transferring the enrollee to the LTACH. The enrollee can remain at the current ACH until such time no acute services are required. The enrollee can then be transferred/discharged to a lower level of care for any ongoing LTC needs.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 Plandoes not haveto pre-approvelong term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay forassay of calcium (82310), assay of parathormone 83970, tissue exam by a pathologist (88305), exploration of parathyroid(s) (60502) and various injections (J0330, J0690, J1100, J1185, J2001, J2250, J2405, J2704) provided on June 27, 2019 by out of network provider, "the doctor". You asked the Plan to pay forassays of calcium and parathormone, tissue exam, and various injections. You say that you are appealing the denial of surgery performed at a non-participating facility, "the hospital", on June 27, 2019. You say that you had a parathyroid tumor and that your previous surgeons would not operate on you due to scar tissue from previous surgeries. You say you had no other recourse but to find other surgeons to help you. Additionally, you say that staff from the provider's office contacted the Plan and you were informed thata pre-authorization was not needed.The Plan denied your request. The Plan says the service received is a covered benefit under your plan. The Plan says you havean HMO plan and must see an in-network provider. The Plan says the provider contacted the Plan on your behalf and was provided with the information they asked for. The Plan also says that youself-referred to an out-of-network provider outside yourservice area.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 forassay of calcium (82310), assay of parathormone 83970, tissue exam by a pathologist (88305), exploration of parathyroid(s) (60502) and various injections (J0330, J0690, J1100, J1185, J2001, J2250, J2405, J2704) provided on June 27, 2019 by out of network provider, "the doctor".