Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care rendered on December 21, 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 the services are not covered.

The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician. 

We looked at the file and Medicare rules. The file shows that procedure code 99291 (critical care services) was billed on the same date of service from a provider in the same physician group. 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 subsequent hospital care rendered on December 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of a percutaneous nerve field stimulator (PNFS) system Class II device.
You asked the Plan to pre-approve PNFS device. You say that this procedure is cleared by the Food & Drug Administration (FDA), is covered by Medicare, and the enrollee is likely to obtain significant therapeutic benefit from it. The Plan denied your request. The Plan says the denial of authorization for this procedure is correct, because this device is an electro-acupuncture device that is not a covered Medicare benefit.
The Plan must follow Medicare rules. Medicare rules say that a percutaneous nerve field stimulator (PNFS) is non-covered when used for stimulation of auricular acupuncture points for any indication. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PNFS device have not been met. Therefore, we decided that the Plan does not have to pre-approve use of a percutaneous nerve field stimulator (PNFS) system Class II device.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee orthosis provided on October 9, 2020.

You asked the Plan to pay for knee orthosis. You say that you have submitted all documents necessary to make a determination of the medical necessity of the item provided. The Plan denied your request. The Plan says the denial of payment for this item is correct, because the enrollee did not receive a video or telephonic visit by the ordering physician to support the item billed.

The Plan must follow Medicare rules. Medicare rules say that a face-to-face encounter is required within the 6 months prior to prescribing an item.

We looked at the file and Medicare rules. The documentation does not include a face-to-face encounter within the 6 months prior to this item being prescribed, and the records submitted do not show that this order was based on an approved use of telehealth examination for the purposes of ordering DMEPOS items. Based on this information, we decided that Medicare rules for coverage of knee orthosis have not been met. Therefore, we decided that the Plan does not have to pay for a knee orthosis provided on October 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care (99223) provided on November 14, 2020.

You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration because this is a separately billable service. The Plan denied your request. The Plan says CPT code 99223 was denied because it was reported on the same day as another evaluation and management service CPT code 99233 which was billed by same provider.

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 the initial hospital care has a bundled relationship with code 99233 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 initial hospital care (99223) provided on November 14, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Contour Next blood glucose test strips.
You asked the Plan to pre-approve the test strips. You say that this is medically necessary. The Plan denied your request. The Plan says this is the non-preferred brand.
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 the test strips. Our reviewer says that the requested test strips are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the request is for a non-preferred brand of glucose strips. The records provided do not indicate a medical reason why the enrollee cannot use the preferred brand. 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 test strips have not been met. Therefore, we decided that the Plan does not have to pre-approve the Contour Next blood glucose test strips.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing services.
You asked the Plan to pre-approve the skilled nursing services. You say that you are unable to progress with
getting better without the professional setting of a skilled nursing facility with the appropriate care. The Plan
denied your request. The Plan says the services at request are not reasonable and necessary for the treatment of
your condition.
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 skilled nursing services. Our
reviewer says that you do not meet the Medicare criteria for SNF care. Our physician reviewer found you do
not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled
professional nurse. You do not have daily skilled therapy needs that requires the specialized skill, knowledge,
and judgment of a skilled professional therapist. You do not require daily skilled nursing and/or skilled therapy
on an inpatient basis in a SNF 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 skilled nursing services have not been met. Although you have skilled
therapy needs, these needs are not on a daily basis. Therefore, we decided that the Plan does not have to preapprove
skilled nursing services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the gene analysis provided by an out-of-network provider on
September 30, 2020.
You asked the Plan to pay for the gene analysis. You say that the test is medically necessary for the diagnosis
or detection of a disease. You say that you are requesting coverage for the test. The Plan denied your request.
The Plan says prior authorization was required but not 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 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 gene analysis provided by an out-of-network
provider on September 30, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the power wheelchair accessories (E2313, E2311, E2377) provided on July 21, 2020.

You asked the Plan to pay for the power wheelchair accessories. You say that you would like reconsideration because this is a non-participating provider and the claim should be processed per Medicare guidelines. The Plan denied your request. The Plan says the billed supply codes are not eligible for billing with modifier NU.

The Plan must follow Medicare rules. The rules say that as of January 1, 2011, standard power wheelchairs are only available as capped rental items. Lump-sum purchase is not permitted. 

We looked at your request, the file and Medicare rules. Based on this information, we have decided that the Plan's decision to deny payment is correct. Specifically, this claim has been billed with the NU modifier, indicating that this equipment has been purchased. The NU modifier is not appropriate for the items billed. Therefore, we decided that the Plan does not have to pay for the power wheelchair accessories (E2313, E2311, E2377) provided on July 21, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. The Plan denied your request. The Plan says you do not require an intensive, complex, multidisciplinary approach to daily therapy.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 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 physician reviewer found that you were admitted to the acute hospital for sepsis and a right hemicolectomy. Your medical problems are stable. There are no complex nursing needs. You do not require treatment by multiple therapies, including either physical or occupational therapy, in an intensive rehabilitation therapy program. 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Ketamine.
You asked the Plan to pre-approve Ketamine. You say that the requested treatment is a necessity for the enrollee. The Plan denied your request. The Plan says the requested off-label use is experimental or investigational.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Ketamine. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found that the enrollee has diffuse pain, cervicalgia, and fibromyalgia. The enrollee has tried acupuncture, massage, and physical therapy. The enrollee has tried multiple drug classes without significant relief. The enrollee has had cervical epidural steroid injection as well as a spinal cord stimulator placed without significant benefit. The requested use of Ketamine is not FDA-approved for the enrollee's diagnosis. The use is not supported by one of the major drug compendia. The enrollee does not have documented treatment-resistant depression and so Esketamine would also not be appropriate. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Ketamine have not been met. Therefore, we decided that the Plan does not have to pre-approve treatment with Ketamine.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the co-payment for nail debridement provided on January 7, 2021.

You asked the Plan to waive the co-payment for the nail debridement. You say that this was a simple routine toenail clip. You say that you didn't have a co-payment for this last year. The Plan denied your request. The Plan says the co-payment applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $10 co-payment for podiatry services. Covered services include diagnosis and the medical or surgical treatment of injuries and diseases of the feet.

You have been asked to pay a $10 co-payment for the nail debridement. The nail debridement falls within the "Podiatry 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 co-payment for nail debridement provided on January 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the office visit provided on February 10, 2021.

You asked the Plan to waive the coinsurance for the office visit. You say that the provider is in-network and the remaining charges should be paid. The Plan denied your request. The Plan says the coinsurance applied correctly.

The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as co-payments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay 50% coinsurance for provider and professional services at an out-of-network specialist's office.

You have been asked to pay $81.21, which is 50% of the allowed amount for the office visit. The allowed amount is $162.42 (50% x $162.42 = $81.21). The office visit falls within the "Physician/Practitioner services, including doctor's office visits" benefit category. The records show the provider is out-of-network. 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 for the office visit provided on February 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a LTACH for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan
denied your request. The Plan says it is recommended that the enrollee continue to receive care in the acute
care facility for maximum benefit.

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 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 she is 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 admission to a LTACH for the enrollee.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for emergency room services (CPT 99283) provided to the enrollee on August 25, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says this was denied as a duplicate claim line.

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 99283 is "Emergency department visit for the evaluation and management of a patient, which requires these 3 key components: An expanded problem focused history; An expanded problem focused examination; and Medical decision making of moderate complexity." We asked our coding 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our coding reviewer found based on the submitted medical records and claims history documentation, the same provider billed two emergency department visits. One was paid. The second one was not billed with an appropriate modifier. Therefore, based on how the service was billed, it is not eligible for reimbursement consideration.

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 services have not been met. Therefore, we decided that the Plan does not have to pay for emergency room services (CPT 99283) provided to the enrollee on August 25, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services rendered from November 8, 2018 to November 12, 2018.
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 DRG and diagnosis code are not supported.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with diagnosis code G93.41 (metabolic encephalopathy). 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 these services. Our reviewer says that the records do not support the billing DRG and diagnosis code. Our physician reviewer found the enrollee presented to the hospital with altered mental status. Per the records, she was noted to have encephalopathy associated with hypoglycemia. Some degree of altered mental status is almost always present with clinically
significant hypoglycemia. Acute toxic/metabolic encephalopathy encompasses delirium and the acute confusional state is an acute condition of global cerebral dysfunction in the absence of primary structural brain disease. The records did not support the billing of diagnosis code G93.41. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG and diagnosis code as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from November 8, 2018 to November 12, 2018.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the enrollee requires IRF care to return to baseline
function. The Plan denied your request. The Plan says rules for IRF care have not 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 in the Medicare rules section.
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 that the complexity of the enrollee's nursing, medical, and rehabilitation needs does
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The
enrollee was admitted for acute respiratory failure, COVID pneumonia, and pulmonary emboli. The enrollee
does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and
an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or
occupational therapy, there is no documented need for intensive rehabilitation 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 IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
You asked the Plan to pre-approve IRF care. You say that IRF care is medically necessary. The Plan denied your request. The Plan says rules for IRF care have not 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 in the Medicare rules section. 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 you were admitted to an acute care hospital for hip revision surgery. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different 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 acute inpatient rehabilitation facility (IRF) admission and services.