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

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve SNF services. You say that this is medically necessary. The Plan denied your request. The Plan says that the enrollee's record does not show that the enrollee requires daily skilled nursing or daily skilled therapy in a SNF setting.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission for skilled nursing facility (SNF) services for the enrollee.
You asked the Plan to pre-approve the SNF admission. You say that SNF for P/T and O/T to get stronger. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above 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 admission. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. His lungs were clear. His appetite was good. Regarding rehabilitation services, the enrollee received physical therapy (PT), speech therapy (ST) and occupational therapy (OT) in the acute hospital. The enrollee was at a minimal to moderate assist level with functional mobility including gait to 30 feet x 2 with LLE AFO. The enrollee required varying assist with activities of daily living. He had left neglect. Our physician reviewer found that the specialized skill, knowledge and judgment of a skilled professional nurse is not required to safely and effectively provide medically necessary and reasonable treatment. Although there are identifiable skilled therapy service needs,
skilled nursing or skilled therapy services (or a combination of these services) was not medically necessary on a "daily basis" in a SNF. As a practical matter, the enrollee does not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve an admission for skilled nursing facility (SNF) services for enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an EEG provided on July 12, 2019.
You asked the Plan to pay for the EEG. The Plan denied your request. The Plan says the provider is not in
network and there is no authorization on file.
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 an electroencephalography (EEG) provided on July 12, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment foran outpatient hospital clinic visit provided by "the medical center" on September 3, 2019.You asked the Plan to waive the copayment forclinic visit. You say that you do not see how your insurance expects you to pay this kindof expense.The Plan denied your request. The Plan says the copayment amount you are being charged is correct.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 $20 copayment for in-network outpatient hospital clinic visit. You have been asked to pay $20 copayment for clinic visit. Clinic visit falls within the Outpatient Hospital Services benefit category. 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 copayment foran outpatient hospital clinic visit provided by "the medical center" on September 3, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe drug testing coded G0483 provided on January 23, 2019.You asked the Plan to pay forthe drug testing. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the services billed are not supported by the documentation.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 the drug testing.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 patient 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 forthe drug testing coded G0483 provided on January 23, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forobservation care discharge day management (99217) provided by "the doctor" on April 23, 2019.You asked the Plan to pay forobservation care discharge day management. You say that this service should be paid.The Plan denied your request. The Plan says this service was previously paid on claim 820191210219560.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Procedure code 99217 includes all services provided to a patient on the day of discharge from outpatient hospital observation status.We find that CPT code 99217 is not supported in the medical record. Specifically, the record shows that CPT 99217 was billed and paid ona previous claim for the same provider and date of service. Based on this information, we decided that Medicare rules for coverage of observation care discharge day management have not been met.Therefore, we decided that the Plan does not have to pay forobservation care discharge day management (99217) provided by "the doctor" on April 23, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered tohe beneficiary by the provider on April 2, 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 codes 44204 and 44188 are 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 44204 is laparoscopy, surgical; colectomy, partial, with anastomosis. The definition of code 44188 is laparoscopy, surgical, colostomy or skin level cecostomy. We find that CPT codes 44204 and 44188 are not supported in the medical record. Specifically, the records do not include documentation of a surgical laparoscopic partial colectomy with anastomosis to support code 44204 and do not contain documentation of a surgical laparoscopic colostomy or skin level cecostomy to support code 44188. 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 rendered to he beneficiary by the provider on April 2, 2019.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered to the enrollee on August 6, 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 codes 95938 and 95861 are not separately payable.
The Plan must follow Medicare rules. Medicare rules say that modifier -26 is required for separate payment of the PC of radiology services when furnished in a different payment locality than the TC. We looked at the file and Medicare rules. Codes 95938 and 95861 were not billed with the required -26 modifier to allow for separate payment of the professional component. Therefore, we decided that the Plan does not have to pay for the testing services rendered to the enrollee on August 6, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on April 16, 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 the claim was not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for an independent laboratory; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered to the enrollee on April 16, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered to the enrollee on January 16, 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 38220 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 38220 is diagnostic bone marrow; aspiration(s). We find that CPT code 38220 is not supported in the medical record. Specifically, the records do not include documentation that a diagnostic bone marrow aspiration was performed. 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 to the enrollee on January 16, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says alternate settings can be requested and reviewed.
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 requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy may be more appropriate. It is not clear that the enrollee would be able to fully benefit and/or participate in an IRF 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approvecervical facet joint injections (64490, 64491, and 64492) to be provided by out of network provider, "the provider". You asked the Plan to pre-approvecervical facet joint injections. You say that the requested medications are medically necessary.The Plan denied your request. The Plan says there are in-network providers that are able to provide this service. Therefore, coverage criteria has not been met.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 pre-approve 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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvecervical facet joint injections (64490, 64491, and 64492) to be provided by out of network provider, "the provider".
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nasal/sinus endoscopy coded 31288 and the nasal/sinus endoscopy services coded 30140 provided on February 25, 2019.
You asked the Plan to pay for the nasal/sinus endoscopy and the nasal/sinus endoscopy services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 find that CPT codes 31288 and 30140 are not supported in the medical record. Specifically, the documentation did not include documentation of a surgical nasal/sinus endoscopy with sphenoidotomy; with removal of tissue from the sphenoid sinus; therefore. code 31288 cannot be verified. In addition, in the narrative of the operative report the requested CPT code was not documented; the note documents an intramural ablation. Submucous resection of inferior turbinates requires removal of tissue; intramural ablation of turbinates does not. As a result, code 30140 is not substantiated by the clinical documentation in the operative report submitted for review. Based on this information, we decided that Medicare rules for coverage of the nasal/sinus endoscopy and the nasal/sinus endoscopy services have not been met. Therefore, we decided that the Plan does not have to pay for the nasal/sinus endoscopy coded 31288 and the nasal/sinus endoscopy services coded 30140 provided on February 25, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment fora CT scan provided at "the hospital" on January 28, 2019.You asked the Plan to waive the copayment fora CT scan. You say that you disagree with the charges.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.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 $60 copayment for diagnostic radiology services. You have been asked to pay a $60 copayment for a CT scan. A CT scan falls within the outpatient diagnostic tests and therapeutic services and supplies benefit category. 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 copayment fora CT scan provided at "the hospital" on January 28, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0483 provided on August 7, 2019.
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 billed are not supported by the documentation.
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 find that CPT codes 80307 and G0483 are not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests are to be performed. The submitted documentation does not itemize what tests are included in this panel; therefore, the billed codes cannot be verified. 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 80307 and G0483 provided on August 7, 2019.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to pre-approvea Brain PET-CT Metabolic Evaluation for "the beneficiary".  You asked the Plan to pre-approvea Brain PET-CT Metabolic Evaluation. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says that the requested services are not medically necessary.The Plan must follow Medicare rules. Medicare rules say that PET scans 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 a Brain PET-CT Metabolic Evaluation. Our reviewer says that the documentation supports that the requested services are medically reasonable and necessary. Our physician reviewer found the NCD states that (FDG (2-[F18] fluoro-2-deoxy-D-glucose) Positron Emission Tomography (PET) is a minimally-invasive diagnostic imaging procedure used to evaluate glucose metabolism in normal tissue as well as in diseased tissues in conditions such as cancer, ischemic heart disease, and some neurologic disorders. The enrollee in this case has a neurologic disorder in the form of medically refractory seizures. An FDG PET may be considered useful in the evaluation of enrollees with medically refractory epilepsy. The enrollee's MRI revealed subtle atrophy in the right hemisphere, and the neurologist suspects that the most active epileptic focus is in the right posterior quadrant region. The requested FDG PET is medically reasonable and necessary in determining the future management of the enrollee's refractory seizures.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Brain PET-CT Metabolic Evaluation have been met.Therefore, we decided that the Plan has to pre-approvea Brain PET-CT Metabolic Evaluation for "the beneficiary". 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forthe topical application of fluoride varnish (code D1206) provided on August7, 2019.You asked the Plan to pay forthe topical application of fluoride varnish. You say that you believe you should be reimbursed for the topical application because your Optional Supplemental Package #2 states that two fluoride treatments are covered per year.The Plan denied your request. The Plan says this service is not covered by the Plan.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, only topical application of fluoride (code D1208) is a covered benefit. Topical application of fluoride varnish (code D1206) is not covered under this benefit.Therefore, we decided that the Plan does not have to pay forthe topical application of fluoride varnish (code D1206) provided on August 7, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve subsequent hospital care (99233) provided by Southeastern Hospitalist Physicians February 27, 2019.
You asked the Plan to pre-approve subsequent hospital care provided. You say that you ask that all submitted information is reviewed and reconsider the medical claim for payment. The Plan denied your request. The Plan says the documents submitted does not support level of care.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve subsequent hospital care provided. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the visit note of 2/27/19 does not meet criteria. The history is limited. The exam is detailed but the medical decision-making is not high complexity. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of subsequent hospital care provided have not been met. Therefore, we decided that the Plan does not have to pre-approve subsequent hospital care (99233) provided by Southeastern Hospitalist Physicians February 27, 2019.