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

We decided that the Plan does not have to pre-approvean acute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that an IRF admission is medically necessary for the enrollee.The Plan denied your request. The Plan says that the enrollee does not meet criteria for coverage of an IRF admission.The Plan must follow Medicare rules. The rules say that an 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 that the complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for lumbar fusion. Her medical conditions are stable. There are no medical needs requiring an inpatient admission. There are no complex nursing or rehabilitation needs.The patient does not require treatment by multiple therapies, including either physical therapyor occupational therapy, and an intensive rehabilitation therapy program. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.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-approvean acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plandoes not haveto pay forshoe holders (K0108) for the enrollee.You asked the Planto pay forthe shoe holders. You say that this is medically necessary.The Plandenied your request. The Plansaysthe requested shoe holders are properly coded E0951 and/or E0952.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 K0108 is "wheelchair component or accessory, not otherwise specified."We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the shoe holders. Our reviewer says that the requested services were coded inappropriately. Our physician reviewer found HCPCS K0108 would not be billed when a more specific HCPCS code can be reported.  Per Medicare "Suppliers must not bill this miscellaneous code when billing for shoe holders or replacement straps.  Complete shoe holders are billed using one of the two or both following HCPCS codes, as applicable. E0951 -HEEL LOOP/HOLDER ANY TYPE, WITH OR WITHOUT ANKLE STRAP, EACH; E0952 -TOE LOOP/HOLDER, ANY TYPE, EACH". Billed items should be reported with the highest degree of accuracy and completeness.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 shoe holders have not been met.Therefore, we decided that the Plandoes not haveto pay forshoe holders (K0108) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fortransesophagealechocardiogram (93321) Doppler echocardiography (93325) echocardiography Procedures (93356).You asked the Plan to pay fortransesophageal echocardiogram. You say that the records provided should support the necessity of the service in dispute.The Plan denied your request. The Plan says the provided records do not include procedure reports of any of the services billed o the claim.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 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 pay for transesophageal echocardiogram. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found based on the records provided the enrollee underwent a transthoracic echocardiogram but not a transesophageal echocardiogram (TEE). Also, the records do not support the medical necessity for a transesophageal echocardiogram.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of transesophageal echocardiogram have not been met.Therefore, we decided that the Plan does not have to pay fortransesophageal echocardiogram (93321) Doppler echocardiography (93325) echocardiography Procedures (93356).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forspecialist services provided on January 15, 2020 by an out of network (OON) provider.You asked the Plan to pay forspecialist services. You say that you would like this claim reprocessed and paid. You say that the patient did not show any insurance information originally.The Plan denied your request. The Plan says prior authorization was not obtained. The Plan says that these services could have been provided in-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 forspecialist services provided on January 15, 2020 by an out of network (OON) provider
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care.You asked the Plan to pre-approveSNF care. You say that this is medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found based on the submitted medical records, the enrollee does not have documented skilled nursing or therapy needs. The enrollee is limited by his weight bearing status and cognition. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs are custodial and, as a practical matter, can be provided at a lower 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 SNF care have not been met.Therefore, we decided that the Plan does not have to pre-approveskilled nursing facility (SNF) care
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute IRFadmission and services.You asked the Plan to pre-approveIRF care. You say that the stay is medically necessary.The Plan denied your request. The Plan says the stay is not medically necessary.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 complexity of the patient's nursing, medical and rehabilitation needs do notrequire an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient's medical status does not require intensive physician or nursing supervision in an IRF. While the patient may benefit and participate in multiple therapies the patient's functional level does not require this on an intensive rehabilitation therapy program provided in an IRF.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 IRF admission and services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay forbitewing -two X-rays (D0272) provided on September 30, 2020.You asked the Plan to pay forbitewing -two X-rays. You say that you were unaware there was a limit for this particular service.The Plan denied your request. The Plan says you have exhausted your benefit for the service received.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. The Plan covers bitewing -two X-rays once everycalendar year. We looked at the file and Medicare rules. The case file indicates that you last received this service in March 2020 and have exhausted the benefit until March 2021. Based on this information, we decided that the Plan's rules for coverage of bitewing -two X-rays have not been met.Therefore, we decided that the Plan does not have to pay forbitewing -two X-rays (D0272) provided on September 30, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvedental services (D2790) for the enrollee.You asked the Planto pre-approvethe services. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit.Therefore, we decided that the Plandoes not haveto pre-approvedental services (D2790) for the enrollee
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forradiology services (CPT 70450) provided to the enrollee on August 13, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says a secondary diagnosis code was reported as the primary code.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 70450 is "computed tomography, head or brain, without contrast material."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 the medical records provided indicate that CPT 70450 was submitted to the health plan with diagnosis code F05 (delirium due to know physiological condition) as the primary diagnosis code and diagnosis J12.89 as the secondary diagnosis code. Per the ICD-10 Manual under the Official Guidelines for Coding and Reporting, diagnosis F05 requires the underlying condition be coded first. Because this claim was submitted with diagnosis F05 as the primary diagnosis, CPT 70450 is not eligible for reimbursement due to inappropriate billing.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 forradiology services (CPT 70450) provided to the enrollee on August 13, 2020.
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 the enrollee requires acute care on a long term basis which is why an LTACH would be optimal placement.The Plandenied your request. The Plansaysan LTACH is not able to provide clinically superior care. As such, continued inpatient care in the current facility is appropriate.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 enrollee was admitted on 1/4/2021 with altered mental status and shock due to pneumonia, pulmonary embolism, and acute kidney injury. She had a trach and PEG tube placed on 1/19/2021. The enrollee has been weaned from the ventilator to a tracheotomy collar.There is no evidence that the enrollee requires services that are not currently available. 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.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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea standard wheelchair.You asked the Plan to pre-approvea standard wheelchair. You say that you would like the plan to reconsider their denial.The Plan denied your request. The Plan says the requested item is not medically necessary. The Plan follows Medicare rules. Medicare rules say that standard wheelchairs are only covered for certain indications.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 standard wheelchair. Our reviewer says that the documentation does not support that the requested standard wheelchair is medically reasonable or necessary. Our physician reviewer found the enrollee has a history of multiple sclerosis. The documentation does not reveal that the enrollee has a personal mobility deficit that impairs participation in mobility related activities of daily living or why that the enrollee has a mobility deficit that requires the use of a walker, cane or manual wheelchair. The enrollee has normal gait, can walk several blocks, and does not use any durable medical equipment currently. The documentation does not support that a manual wheelchair will significantly improve the enrollee's ability to participate in mobility related activities of daily living in the home and that the enrollee will use it on a regular basis in the home. While the enrollee may be able to safely navigate the requested wheelchair the documentation does not support that it is medically necessary.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a standard wheelchair have not been met.Therefore, we decided that the Plan does not have to pre-approvea standard wheelchair.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approvea referral to an out-of-network dentist.You asked the Planto pre-approvethe referral. You say that this is medically necessary.The Plandenied your request. The Plansaysthis is not a covered benefit.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. The plan covers dental services when they are providedby a network provider.The requested dentist is not participating with the plan. Based on this information, we decided that the Plan's rules for coverage of the referral have not been met.Therefore, we decided that the Plandoes not haveto pre-approvea referral to an out-of-network dentist.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe extremity study and portable x-ray services rendered on June 23, 2020.You asked the Plan to pay forthese 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 a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes.We looked at the file and Medicare rules. The provider billed codes 93971 and R0070. These codes have a PC/TC indicator of 3 and no separate PC payment.Therefore, we decided that the Plan does not have to pay forthe extremity study and portable x-ray services rendered on June 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forinfectious agent testing (87798) provided on November 7, 2019.You asked the Plan to pay forinfectious agent testing. You say that this should be covered.The Plan denied your request. The Plan says this cannot be paid as billed.The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied.In this case, the MUE for CPT code 87798 is 13. You billed 17 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of infectious agent testing have not been met.Therefore, we decided that the Plan does not have to pay forinfectious agent testing (87798) provided on November 7, 2019
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approvea set of partial dentures (D5214, D5213).You asked the Plan to pre-approvethe partial dentures. You say that your existing dentures have been nothing but problems and you want a replacement.The Plan denied your request. The Plan says the benefit for dentures has been exhausted. The plan provides coverage for repairs.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. One set of partial or complete dentures is covered by theplan every 5 years.Though the Plan offers a dental benefit in excess of Medicare coverage, the benefit for dentures has been exhausted at this time. Dentures were previously provided on September 23, 2019.Therefore, we decided that the Plan does not have to pre-approvea set of partial dentures (D5214, D5213).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forimmunization, influenza vaccine (Q2039) provided September 18, 2019.You asked the Plan to pay forthe vaccination. You say that you left the country for a month and wished to have your flu shot before departing. Your primary physician's office was out of the vaccine so you went to your pharmacy.The Plan denied your request. The Plan says timely filing not met. Claim submitted after contract time limit.The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.The record shows that a claim for the vaccination was not filed until October 2, 2020. This means that more than one calendar year from the date of service had passed before a claim was filed.Therefore, we decided that the Plan does not have to pay forimmunization, influenza vaccine (Q2039) provided September 18, 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. You say that you are not able to be on your own and need rehabilitation to participate in daily life.The Plan denied your request. The Plan says this is not medically necessary.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 complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical treatment of a hip fracture after a fall and your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. While the medical record documents a need for physical and occupational therapy, it does not document a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.We looked at this physician's review, the file, and Medicare rules. Based onthis 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