Persius/hicric huggingface dataset:
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 enrollee can tolerate an aggressive therapy program. The Plan denied your request. The Plan says the enrollee would be safely and equally well-served with skilled therapy services at an alternate level of care, such as discharge to a skilled nursing facility with skilled 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 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 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 surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. 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. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from November 29, 2020, through November 30, 2020.

You asked the Plan to pay for the inpatient care. You say that the enrollee met criteria for an inpatient level of care that was medically necessary and reasonable. The Plan denied your request. The Plan says there is not any clinical documentation in the record supporting instability on or after 10:01 am on November 29, 2020.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required. 

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 inpatient care. Our reviewer says that the inpatient care does not meet criteria. Our physician reviewer found that as of 10:01 a.m. on November 29, 2020 the enrollee was hemodynamically stable and appropriate for ambulance transport with monitoring to a Plan facility for inpatient level of care services. The post-stabilization care service form 10:01 a.m. November 29, 2020, through November 29, 2020 to 9:35 p.m. on November 30, 2020 at the non-Plan facility were not needed on an emergent basis. The treating physician did not document (in the physician notes, on a form, or in an order) that the enrollee was not stable for transfer on any dates of service. 

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 inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient care provided from November 29, 2020, through November 30, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Guardant360 testing provided on August 24, 2020.
You asked the Plan to pay for the Guardant360 testing. You say that the Guardant360 testing provided was medically necessary. The Plan denied your request. The Plan says the enrollee did not meet criteria for the Guardant360 testing provided.
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 pay for the Guardant360 testing. Our reviewer says that the enrollee did not meet criteria for the Guardant360 testing provided. Our physician reviewer found the record indicates that the enrollee has an invasive high-grade papillary urothelial carcinoma of the bladder. The enrollee has had a tissue biopsy. The records provided are insufficient to demonstrate satisfaction of the coverage criteria. The coverage criteria are not satisfied. The requested service cannot be recommended. 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 Guardant360 testing have not been met. Therefore, we decided that the Plan does not have to pay for the Guardant360 testing provided on August 24, 2020.
Appeal type: Transportation
Decision: Favorable

We decided that the Plan has to pay for the ambulance services provided on January 8, 2021.
You asked the Plan to pay for the ambulance services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says that the services are not covered.
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. In this case, the Plan denied payment for an ambulance response with no transport (A0998) provided on January 8, 2021. We sent the Plan a request for the ambulance response records as the Plan did not include a request for these records in the original case file sent to us. We are unable to verify if the no transport criteria or paramedic intercept criteria have been met without this information that should have been included with the original case file for review. Therefore, we decided that the Plan has to pay for the ambulance services provided on January 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the Anser ADA testing rendered on August 25, 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 testing is not covered.
The Plan must follow Medicare rules. The rules say that MolDX will reimburse approved tests. We looked at the file and Medicare rules. The test at issue was not approved through the MolDX program for the date of service at issue. 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 Anser ADA testing rendered on August 25, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on March 11, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are not supported.
The Plan must follow Medicare rules. Medicare rules say that the physician must clearly document, in the medical record, his or her intent that the test be performed. We looked at the file and Medicare rules. The records provided do not contain documentation of the ordering physician's intent that the tests be performed.
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 drug testing services provided on March 11, 2020.
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 you are already in the hospital and should not go home when you are so weak. You say that you could hurt yourself if you were to return home at this time. The Plan denied your request. The Plan says the guidelines for coverage of SNF care have not been met. The Plan says that the enrollee can receive the care needed in another 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 medications and had stable vital signs. The enrollee was at a contact guard to minimal assist level with function mobility, including gait to 200 feet with a rollator. 

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit represented by code 99285 and the electrocardiogram (ECG) report represented by code 93010 provided on September 25, 2020.

You asked the Plan to pay for codes 99285 and 93010. You say that the medical records support the billing of codes 99285 and 93010. The Plan denied your request. The Plan says the medical records do not support the billing of codes 99285 and 93010.

The Plan follows Medicare billing and payment rules. The rules say that codes billed must accurately reflect the services provided.

In this case, you billed CPT code 99285. The definition of CPT code 99285 is an emergency room visit for the evaluation and management of a patient which requires three components (taking into account the urgency of the clinical condition or the patient's mental status):

1. a comprehensive history; 
2. a comprehensive examination; and 
3. medical decision making of high complexity.

In addition, CPT code 99285 usually includes a presenting medical problem of high severity and immediate significant threat to life or physiologic function.

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 codes 99285 and 93010. Our reviewer says that the medical records do not support the billing of codes 99285 and 93010. Our reviewer found the record indicates that the enrollee was evaluated in the emergency room. The enrollee underwent an electrocardiogram. The provider billed for the electrocardiogram. The interpretation of the electrocardiogram cannot be included to determine medical complexity when separately billed. The provided record does not support the presence of high complexity medical decision making. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of codes 99285 and 93010 have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department visit represented by code 99285 and the electrocardiogram (ECG) report represented by code 93010 provided on September 25, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder arthroscopy surgery provided on July 8, 2020.

You asked the Plan to pay for shoulder arthroscopy surgery. You say that this code is supported in the records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this procedure code 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 29824 is arthroscopy, shoulder, surgical; distal claviculectomy including distal articular surface. 

We asked our coder 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 shoulder arthroscopy surgery. Our reviewer says that this code does not meet the criteria for payment. Our reviewer found the operative report does not include documentation of excision of bone from the distal clavicle/joint. Per the operative report, "Next, a high-speed cutting bur was inserted through the anterior portal to complete a coplaning of the distal clavicle. The interior osteophyte was completely removed, and there was adequate space between the distal clavicle and the medical acromion." Therefore, code 29824 would not be covered. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of shoulder arthroscopy surgery have not been met. Therefore, we decided that the Plan does not have to pay for shoulder arthroscopy surgery provided on July 8, 2020.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for pathology services (procedure code 88120) provided on February 5, 2021.
You asked the Plan to pay for the pathology services. You say that these pathology services were ordered by the patient's doctor. The Plan denied your request. The Plan says that this test is considered a screening and is therefore non-covered.
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. In other words, the Plan must provide it its case file sent to the IRE all information upon which they relied to support their denial. We find that the Plan has not met its burden of showing why these pathology services should not be covered. The Plan's sole basis for denial is because these pathology services were ordered as screening services. No other argument for non-coverage was provided by the Plan. There is no evidence that these pathology services were ordered as screening services. In fact, they were ordered and billed with a specific diagnosis code (R31.29- hematuria), which is indicative of the fact that the patient had a condition or symptom for which the testing was ordered. This is completely contrary to the definition of 'screening'. Because the Plan has offered no other basis for denial, and because this sole 'screening' argument is not appropriate based on how the services were billed and the medical records (including the order from the referring doctor), we do not agree with the Plan's denial. Therefore, we decided that the Plan has to pay for pathology services (procedure code 88120) provided on February 5, 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on October 2, 2020.

You asked the Plan to pay for the lab services. You say that these lab services should be paid. The Plan denied your request. The Plan says the Place of Service reported on the claim is not correct.

The Plan must follow Medicare rules. Medicare rules say that lab services should be billed with the Place of Service where the specimen was collected from the patient. In this case, you billed with Place of Service 81, which would indicate that the lab itself collected the specimen. However, the medical records show that the patient's specimen was NOT collected at the lab, but by the patient's doctor. The patient's doctor then sent the sample to your lab for processing. Based on Medicare rules, you should have entered the Place of Service where the specimen was collected on the 1500 Claim Form.

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on October 2, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the neurology visit you provided on February 23, 2021.
You asked the Plan to pay for the neurology visit. You say that you have treated this patient for years and with
your care they have stayed in remission. The Plan denied your request. The Plan says unauthorized, non-plan
care is not covered.
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.
You are not a network provider with the Plan. You did not have prior authorization to provide these services to
the enrollee. 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 neurology visit you provided on February 23, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99238) provided on March 24, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code cannot be verified.

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 99238 is "Hospital discharge day management; 30 minutes or less."

We asked our coder 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 use of code 99238 is not supported by the records provided. Our reviewer found that the records indicate that the enrollee was discharged upon death on March 24, 2020. The provided records do not indicate that the requesting physician pronounced death. The elements of the coverage criteria are not satisfied. 

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 the services (99238) provided on March 24, 2020.
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 February 1, 2021 to February 24, 2021.
You asked the Plan to pay for home health services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.
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 rules say the Type of Bill is a required data element needed to submit a claim under home health PPS. This 4-digit code gives two pieces of information. The first three digits indicate the base type of bill. The fourth digit indicates the sequence of this bill in this particular episode of care. The types of bill accepted for HH PPS requests for anticipated payment are either 7, 8, or 9 as defined above. HHAs must submit HH PPS claims with the 4th digit of "9." Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from February 1, 2021 to February 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for vision services provided on February 22, 2021.

You asked the Plan to pay for the vision services. The Plan denied your request. The Plan says You must receive your care from a network provider. In most cases, care you receive from an out-of-network provider will not be covered. If you need medical care that Medicare requires our plan to cover and the providers in our network cannot provide this care, you can get this care from an out-of-network provider. You, or your PCP, must obtain authorization from the plan prior to seeking care. In this situation, you will pay the same as you would pay if you got the care from a 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 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 vision services. 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 vision services provided on February 22, 2021.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pay for a skilled nursing visit provided on December 29, 2020.

You asked the Plan to pay for skilled nursing visit. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because this code cannot be billed with a physician.

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 G0162 is skilled services by a registered nurse (RN) for management and evaluation of the plan of care; each 15 minutes. 

We asked our coder 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 skilled nursing visit. Our reviewer says that this procedure code meets the criteria for payment. Our reviewer found the documentation submitted includes a home visit by a registered nurse (RN) for the date of service billed. This service was billed by the provider. Therefore, this procedure code would be covered. 

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of skilled nursing visit have been met. Therefore, we decided that the Plan has to pay for a skilled nursing visit provided on December 29, 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.