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.

You asked the Plan to pre-approve the SNF services. You say that the records provided support the need for care in a SNF. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan say that the enrollee is not medically stable, and her needs may be met in the current hospital setting.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral and inhaled medications and insulin. The enrollee received enteral nutrition and had stable vital signs. The enrollee continued dialysis and had wound care to chronic bilateral lower extremity wounds. The enrollee received physical therapy in the acute hospital. The enrollee was at a maximal assist level with functional mobility. There are no identifiable skilled therapy service needs. There are identifiable skilled nursing needs, but they are not required on a daily basis. The enrollee does not meet the severity of illness or intensity of service criteria for 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
You asked the Plan to pre-approve a CGM. You say that this item is medically necessary. The Plan denied your request. The Plan says that you do not inject insulin three or more times a day or require frequent adjustment of insulin.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that you do not use insulin with at least
three daily injections or require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a CGM have not been met. Therefore, we decided that the Plan does not have to pre-approve a Dexcom G6 continuous glucose monitor (CGM).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dermatology services provided on April 8, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for dermatology services. You say that you would like this claim reprocessed and paid. You say that these services were discussed with the member's primary care physician. The Plan denied your request. The Plan says these services can be provided within network.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.

The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for dermatology services provided on April 8, 2021 by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for electrical stimulator supplies provided on April 
28, 2021.

You asked the Plan to pay for the provided items. You say that the item was denied in error. The 
Plan denied your request. The Plan says the claim processed correctly.

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 A4595 is electrical stimulator supplies, 2 
lead, per month. We find that CPT code A4595 is not separately payable. The allowance for the device includes lead 
wires. Based on this information, we decided that Medicare rules for coverage have not been met. 
Therefore, we decided that the Plan does not have to pay for electrical stimulator supplies provided on April 28, 
2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on November 20, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure codes 14301, 15002, and 15003 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 14301 is adjacent tissue transfer or rearrangement, any area; defect 30.1 sq cm to 60.0 sq cm. The definition of code 15002 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; first 100 sq cm or 1% of body area of infants and children. The definition of code 15003 is surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar (including subcutaneous tissues), or incisional release of scar contracture, trunk, arms, legs; each additional 100 sq cm, or part thereof, or each additional 1% of body area of infants and children (List separately in addition to code for primary procedure).

We find that CPT codes 14301, 15002, and 15003 are not supported in the medical record. Specifically, there is no documentation of an adjacent tissue transfer or rearrangement for defects 30.1 sq cm to 60.0 sq cm to support code 14301. There is no documentation of surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar for the first 100 sq cm to support code 15002. There is no documentation of surgical preparation or creation of recipient site by excision of open wounds, burn eschar, or scar for each additional 100 sq cm to support code 15003. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on November 20, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room (ER) services you received from March 20, 2021, to March 23, 2021.
You asked the Plan to waive the copayment for the ER services. You say that you were admitted to the hospital so there should be no charge for this service. The Plan denied your request. The Plan says you were charged this copayment correctly because you were not admitted to the hospital as an inpatient.
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 $120 copayment for emergency room services. You have been asked to pay a $120 copayment for the ER services. There are no billed claims showing that you were admitted to the hospital as an inpatient within 24 hours. 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 for the emergency room (ER) services you received from March 20, 2021, to March 23, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 17, 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 were 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 a
laboratory setting; 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 on May 17, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acute inpatient hospital care for shoulder joint replacement surgery (CPT code 23472), for the enrollee.
You asked the Plan to pre-approve acute inpatient hospital care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the procedure is currently approved as an ambulatory procedure. The Plan states there is no documentation provided to support the expectation the enrollee will require a greater than two (2) midnight stay. The Plan states if the enrollee experiences any peri- or post-operative complications, reconsideration for inpatient level of care can be performed on concurrent review with updated clinical information.
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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the enrollee does not have any significant medical history noted in the documentation that might justify inpatient services for this ambulatory procedure. There was no indication the enrollee requires hospital services that would likely cross two (2) 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 not been met. Therefore, we decided that the Plan does not have to pre-approve the acute inpatient hospital care for shoulder joint replacement surgery (CPT code 23472), for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the new patient office visit provided on March 17, 2021.
You asked the Plan to pay for the new patient office visit. You say that the Plan should pay this claim. The Plan
denied your request. The Plan says a previously claim for the same provider was processed on October 10,
2019.
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 99202 is Office or other outpatient visit for the evaluation
and management of a new patient, which requires a medically appropriate history and/or examination and
straightforward medical decision making. When using time for code selection, 15-29 minutes of total time is
spent on the date of the encounter.
We find that CPT code 99202 is not supported in the medical record. Specifically, a new patient is one who has
not received any services from the physician within the past three years. Based on this information, we decided
that Medicare rules for coverage of the new patient office visit have not been met. Therefore, we decided that
the Plan does not have to pay for the new patient office visit provided on March 17, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for discharge day management (99239) provided on December 20, 2019.
You asked the Plan to pay for discharge day management. You say that this is supported in the records. The Plan denied your request. The Plan says this is not documented.
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 99239 is hospital discharge day management; more than 30 minutes.
We find that CPT code 99239 is not supported in the medical record. Specifically, the time spent on this service is not documented in the records. Based on this information, we decided that Medicare rules for coverage of discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for discharge day management (99239) provided on December 20, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve post-cataract surgery to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve eye surgery. You say that you disagree with this denial. The Plan denied your request. The Plan says the denial of authorization for this service is correct, because this provider is out-of-network with the Plan and the enrollee can be treated by an in-network provider.
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 care that cannot be provided by network providers. 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-approve post-cataract surgery to be provided by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a seat lift chair and mechanism.

You asked the Plan to pre-approve a seat lift chair and mechanism. You say that you cannot get up on your own and need a lift chair to put you in a position to stand up. The Plan denied your request. The Plan says a recliner chair is not medical in nature.

The Plan must follow Medicare rules. The rules say that seat lift chairs are not covered. Coverage is limited to a seat lift mechanism. 

We looked at the file and Medicare rules. Although a seat lift chair may be appropriate, Medicare does not cover this item and the Plan must provide coverage only for items that Medicare covers. The medical records do not support the criteria for the mechanism. Therefore, we decided that the Plan does not have to pre-approve a seat lift chair and mechanism.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from January 23, 2021 to February 15, 2021.
You asked the Plan to pay for home health services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the claim is missing required information.
The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered. We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the claim was submitted with an inappropriate type of bill and is missing the required Request for Anticipated Payment (RAP). Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from January 23, 2021 to February 15, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (93000) provided on February 2, 2021.
You asked the Plan to pay for the services. You say that asfafda The Plan denied your request. The Plan says that this is a bundled code and is not separately payable.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan argues that code 93000 is bundled with code 93280. While this is true, the Plan has not provided documentation showing that code 93280 was billed on the same date of service as code 93000. Without supporting documentation, the Plan's denial cannot be substantiated. Therefore, we decided that the Plan has to pay for the services (93000) provided on February 2, 2021.
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 for the occlusal guard provided on April 28, 2021.
You asked the Plan to pay for the provided item. You say that you grind your teeth. The Plan denied your request. The Plan says the service is not covered under your dental 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. Although the Plan offers a dental benefit in excess of Medicare coverage, the item is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the occlusal guard provided on April 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99205) provided on February 8, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not payable.
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 code 99205 is not supported in the medical record. Specifically, code 99205 is assigned a status indicator of "B" under the OPPS. This means that this code is not recognized by OPPS when submitted on an outpatient hospital Part B bill type. 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 the services (99205) provided on February 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (82274, 82656, 83520, 83631, 87338) provided on October 21, 2020.

You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not billed with the correct Plan of service.

The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). 

We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (82274, 82656, 83520, 83631, 87338) provided on October 21, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab testing provided on April 14, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says preventative vitamin assays and metabolic function tests are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.
The file shows that Vitamin D testing was provided. The medical records provided list a diagnosis of Vitamin D deficiency. However, the provider does not address this condition during the visit. Testing may not be used for routine or other screening.
The file also shows that a Hepatitis C screening for individuals at high risk was provided. In this case, there are insufficient medical records to show the enrollee is at high risk. There are no records to indicate this testing was necessary. Therefore, we decided that the Plan does not have to pay for the lab testing provided on April 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.
You asked the Plan to pre-approve a therapeutic continuous glucose monitor. You say that the enrollee only has one arm which makes this device necessary. The Plan denied your request. The Plan says the coverage criteria for the requested device have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan. We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a therapeutic continuous glucose monitor have not been met. Therefore, we decided that the Plan does not have to pre-approve a therapeutic continuous glucose monitor.