Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay foran arthroscopy (29823) provided on March 31, 2020.You asked the Plan to pay foran arthroscopy. You say that this code is supported.The Plan denied your request. The Plan says that this procedure 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 29823 is arthroscopy, shoulder, surgical; debridement, extensive.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 payfor an arthroscopy. Our reviewers say that CPT 29823 is supported by documentation submitted. Our physician reviewer found to support extensive debridement (29823), the documentation should support work in both the front and back of the shoulder.  The most effective documentation, from both a clinical and coding perspective, would identify the areas or compartments in which debridement takes place.  Debridement in a single area or compartment would qualify as limited, while debridement in multiple locations or compartments of the shoulder support the coding of extensive debridement.  To site the operative report "The anterior labrum and superior labrum were debrided until stable tissue was obtained.  The under surface of the rotator cuff was debrided until stable tissue was obtained.  The posterior labrum was debrided with shaver.  The posterior cuff was debrided with shaver.  Subacromial bursa was debrided with shaver. We debrided the leading edge of the cuff."We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an arthroscopy have been met.Therefore, we decided that the Plan has to pay foran arthroscopy (29823) provided on March 31, 2020.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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the services provided on March 11, 2019.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the claim was
submitted after the timely filing 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 services was not filed until August 27, 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 for the services provided on March 11, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay fora pneumatic compression device (E0676).You asked the Plan to pay fora pneumatic compression device. You say that the item in dispute was a medically necessary preventative measure.The Plan denied your request. The Plan says pneumatic compression devices and supplies are not covered by Medicare to prevent deep vein thrombosis during and/or following surgery, at home, or in any setting.The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism (E0676) is a preventive service.We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. This item is used for a preventative service and is excluded from Medicare coverage.Therefore, we decided that the Plan does not have to pay fora pneumatic compression device (E0676)
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on July 16, 2020.
You asked the Plan to pay for the drug testing services. The Plan denied your request. The Plan says the
services with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or
other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.
We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which
would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based
on this information, we decided that Medicare rules for coverage of the drug testing services have not been
met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on July 16,
2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on October 13, 2020 by an out of network (OON) provider.You asked the Plan to pay forthe subsequent nursing facility care and debridement (99308 and 11042). You say that you would like reconsideration because the services rendered were medically necessary and urgent.The Plan denied your request. The Plan says there is no pre-authorization on file and the services were not urgent or emergent.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 forthe medical services provided on October 13, 2020 by an out of network (OON) provider.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF admission.
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 enrollee does not meet criteria for IRF admission. Our physician reviewer found 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 septic shock, uremia and acute renal failure. Medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, in 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. 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: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the opioid treatment services rendered on August 24, 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 provider type is not covered.
The Plan must follow Medicare rules. The rules say that Medicare covers substance use counseling by a professional to the extent authorized under State law to furnish such services. We looked at the file and Medicare rules. The file shows that the services were rendered by a Family Medicine doctor and not a state licensed mental health provider. 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 opioid treatment services rendered on August 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for domiciliary/rest home visit services (CPT 99335) provided to the enrollee on July 28, 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 Medicare says non-urgent services should be from network providers who are contracted with the member's health plan and listed in the Provider Directory.
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 domiciliary/rest home visit services (CPT 99335) provided to the enrollee on July 28, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for audiologic function tests provided on October 13, 2020.
You asked the Plan to pay for audiologic function tests. The Plan denied your request. The Plan says 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 Plan says that the Plan has also determined that these services are not urgent or emergent, nor were they approved in advance.
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 audiologic function tests. 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 audiologic function tests provided on October 13, 2020.
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 these services are medically necessary. The Plan denied your request. The Plan says that your care needs can continue to be met in the skilled nursing facility setting.
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. The complexity of your nursing, medical and rehabilitation needs do 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. Your medical conditions are stable. There are no medical needs requiring inpatient admission. There are no complex nursing or rehabilitation needs. 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 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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe shoulder x-rays (73030) and chest x-ray (71045) provided on June 15, 2020.You asked the Plan to pay forthe x-rays. You say that you would like reconsideration because this member had multiple exams on the same date of service.The Plan denied your request. The Plan says the services at issue have been previously approved and paid by the Plan.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules say for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.We find that CPT codes 73030 and 70145 is not supported in the record. Specifically, the record indicates that the Plan has paid for the codes at issue for this date of service. There is no indication that additional services were rendered.  Based on this information, we decided that Medicare rules for coverage of the x-rays have not been met.Therefore, we decided that the Plan does not have to pay forthe shoulder x-rays (73030) and chest x-ray (71045) provided on June 15, 2020
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 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 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 patient does not require treatment by multiple therapies, including either physical therapy or 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-approveacute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pay forchemotherapy administration services (82565, 96413, 80051, 82247, J9035) provided on March 11, 2020.You asked the Plan to pay forchemotherapy administration services. You say that these services were medically necessary.The Plan denied your request. The Plan says that the payment for these services has been retracted.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 has not provided any reasoning or justification for why the payment for this claim was retracted.Therefore, we decided that the Plan has to pay forchemotherapy administration services (82565, 96413, 80051, 82247, J9035) provided on March 11, 2020.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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services you received from November 19, 2019, to January 15, 2020.
You asked the Plan to pay for the chiropractic services. The Plan denied your request. The Plan says these services are not covered.
The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services you received from November 19, 2019, to January 15, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay forhospital care (99235) provided on August 5, 2019.You asked the Plan to pay forhospital care. You say that these medically necessary services were provided to the enrollee in good faith and that you should not be penalized for delays in the receipt of information from the providing facility.The Plan denied your request. The Plan says rules for payment have not been met.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 hospital care was not filed until September 18, 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 forhospital care (99235) provided on August 5, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay fora psychiatric diagnostic evaluation (90791) provided on July 5, 2019.You asked the Plan to pay fora psychiatric diagnostic evaluation. You say that you depend on the providing facility for timely notification of the enrollee's health insurance coverage and that these medically necessary services were provided to the enrollee in good faith.The Plan denied your request. The Plan says rules for payment have not been met.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 a psychiatric diagnostic evaluation was not filed until August 26, 2020. This means that more than one calendar year from the date of service had passed before a claim wasfiled.Therefore, we decided that the Plan does not have to pay fora psychiatric diagnostic evaluation (90791) provided on July 5, 2019
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approveOrthovisc (J7324).You asked the Plan to pre-approveOrthovisc. You say that the enrollee has tried and failed alternate therapies. You also say that you recommend Orthovisc.The Plan denied your request. The Plan says there is no documentation of physical therapy or trial and failure of medications treatment.The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and 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 Orthovisc. Our reviewer says that Orthovisc (J7324) is not medically reasonable and necessary for the enrollee. Our physician reviewer found current evidence based medical literature supports the use of viscosupplementation for moderate symptomatic osteoarthritis after failure of reasonable conservative measures, which is not documented in this case. Our reviewer found that there is limited documentation supporting that a trial and failure of physical therapy and/or medication therapy has been fully utilized. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request in this enrollee's clinical setting. Our physician reviewer also found that this request for Orthovisc injections for the enrollee's right knee is not medically necessary, safe, effective and/or reasonable.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Orthovisc have not been met.Therefore, we decided that the Plan does not have to pre-approveOrthovisc (J7324).
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to waive the copayment for lab work provided by a participating provider on September14, 2020.You asked the Plan to waive the copayment for lab work. You say that you do not agree with this copayment. The Plan denied your request. The Plan says that the correct copayment has been applied.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $0 copayment for outpatient diagnostic tests/lab services. The Plan says you must pay a $9.71 copayment for lab work. Based on the Plan contract, however, you cannot be asked to pay more than a $0 copayment for lab work. Therefore, we decided that the Plan has to waive the copayment for lab work provided by a participating provider on September 14, 2020. 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.