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

We decided that the Plan does not have to pay for the surgical services rendered to the enrollee on September 6, 2019.
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 code 29823 is 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 29823 is arthroscopy, shoulder, surgical; debridement, extensive. We find that CPT code 29823 is not supported in the medical record. Specifically, the operative report does not contain sufficient documentation showing a surgical shoulder arthroscopy with extensive debridement was performed. 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 to the enrollee on September 6, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
You asked the Plan to pre-approve the compression stockings. You say that you need the stockings for swelling and venous insufficiency. They were approved before and you would like them approved for a period of time so you don't have to call every time you get a prescription. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6549 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6549.
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 requested admission to an IRF does not meet criteria.
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 admission to an IRF does not meet criteria. Our physician reviewer found the enrollee underwent elective surgery on 1/16/20 for a lumbar decompression fracture with decompression laminectomies. Postoperatively she had anemia, acute kidney injury and hyperkalemia which were treated with transfusion and bicarb, kayexalate, and insulin with improvement. She had encephalopathy with rapid response called on 1/20 due to unresponsiveness felt due to opiate use and anemia/dehydration. On 1/18/20 she was contact guard assist for bed mobility, had fair endurance of 1-20 minutes, was moderate assist for grooming, and minimal assist for supine to sit. On 1/21/20 she was moderate assist for supine to sit, minimal assist for sit to stand, ambulated 10 feet x 1 and 20 feet x 1 with contact guard assist. She had a shuffling gait. The complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee's medical conditions do not require intensive physician or nursing oversight in an IRF. While the enrollee may benefit from additional physical therapy and occupational therapy, the documentation does not support that she can tolerate this therapy or requires this therapy on an intensive rehabilitation therapy level 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 pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
You asked the Plan to pre-approve IRF care. You say that the enrollee will not reach maximum independence, unless she has intensive therapy. The Plan denied your request. The Plan says the enrollee's condition is not medically complex, and does not require an interdisciplinary approach/multiple specialists to oversee the enrollee's care.
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 the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that the enrollee requires the intensity of an IRF stay with close physician or nursing supervision. The enrollee is tolerating an oral diet. The documentation does not reveal uncontrolled pain, significant anemia or uncontrolled lab results or vital signs. The enrollee may benefit and participate in additional therapy of PT and OT but the enrollee does not require this on an intensive rehabilitation facility therapy program level 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on July 15, 2019.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 G0483 is drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of 22 or more drug classes. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on July 15, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be safely managed at a skilled nursing facility and requires prolonged hospitalization as well as the intensive skilled services that are offered in the LTACH setting. The Plan denied your request. The Plan says the enrollee can remain in the current acute care location until such time as no further acute level care is needed.
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 is currently undergoing treatment at an ACH for multiple injuries after being struck by a car. The enrollee was intubated/ventilated and subsequently received a tracheotomy. The enrollee has since been weaned off the ventilator to a tracheotomy collar. The enrollee is participating in rehabilitative services. 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. The enrollee can then be transferred/discharged to a lower level of care for any ongoing long term care needs. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a long term acute care hospital (LTACH) for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99215) provided on September 11, 2019 by out of network provider.
You asked the Plan to pay for an office visit. You say that you are appealing the claim payment denial for services rendered to the Plan's member on date of service September 11, 2019. The Plan denied your request. The Plan says the doctor and the rendering facility are non-participating providers. The Plan says it did not authorize any services for the facility or the doctor. The Plan also says that there are multiple in-network providers within 30 miles of the members residence that could have rendered the services. The services were not considered urgent/emergent in nature.
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 has network providers available who can provide 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 an office visit (99215) provided on September 11, 2019 by out of network provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for home infusion therapy (99601 and 99602) provided on July 8, 2019.
You asked the Plan to pay for the home infusion therapy. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 99601 and 99602 have a status code of I which is not valid for Medicare purposes.
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 CPT codes 99601 and 99602 are not supported in the record. Specifically, per the 2019 Physician Fee Schedule, 99601 and 99602 have a status code of I. This means that 99601 and 99602 are not valid for Medicare purposes. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for home infusion therapy (99601 and 99602) provided on July 8, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient skilled nursing facility care (SNF) services provided from April 1, 2018 to April 6, 2018.
You asked the Plan to pay for these services. You say that you are requesting reconsideration of the Plan's denial of payment. The Plan denied your request. The Plan says Original Medicare is responsible for coverage of Part B benefits starting on the date of election until the last day of the month in which hospice is revoked.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal. Therefore, we decided that the Plan does not have to pay for the inpatient skilled nursing facility care (SNF) services provided April 1, 2018 to April 6, 2018.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care (99309) provided on June 20, 2019 by out of network provider.
You asked the Plan to pay for subsequent nursing facility care. You say that while it is true that you are out-of-network, the facility is in-network. You say that the patient has no choice in the medical professionals they are seen by while in the facility. You say that you rely on the facility to obtain any necessary authorizations when your providers are asked to see patients at their facilities for medical treatment. You also say the medical records prove medical necessity. The Plan denied your request. The Plan says services rendered were billed as an out-of-network provider and per the enrollee's contract skilled nursing facility (SNF) care requires prior authorization. The record does not show that prior authorization was obtained for this out-of-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 has network providers available who can provide 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 subsequent nursing facility care (99309) provided on June 20, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on April 30, 2019 to May 29, 2019 by out of network provider.
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 rendered by a non-network provider without prior authorization.
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 has network providers available who can provide 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 the medical services provided on April 30, 2019 to May 29, 2019 by out of network provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a test for detecting genes associated with rheumatoid arthritis (81490) provided on September 9, 2019 by out of network provider.
You asked the Plan to pay for a test for detecting genes associated with rheumatoid arthritis. You say that you are appealing claim payment denial for services rendered to the Plan's member on date of service September 9, 2019. The Plan denied your request. The Plan says the referring provider is a non-participating facility. The Plan says that referring provider is a non-participating provider. The plan says they did not authorize any services. The Plan also says that there are multiple in-network providers within 30 miles of the members residence that could have rendered the services. The services are not considered urgent/emergent in nature.
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 has network providers available who can provide 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 a test for detecting genes associated with rheumatoid arthritis (81490) provided on September 9, 2019 by out of network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services rendered to the enrollee on April 24, 2019.
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 code 99053 is not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. The provider submitted a claim for procedure code 99053 (Service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service). This code has a status indicator of B and does not have separate payment. Therefore, we decided that the Plan does not have to pay for the services rendered to the enrollee on April 24, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on August 29, 2019 by out of network provider.
You asked the Plan to pay for outpatient hospital services. You say that the doctors perform these services in good faith. The Plan denied your request. The Plan says no prior authorization was obtained. The Plan says that there are multiple in-network providers available with 30 miles of the member's residence that could have rendered these services.
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 has network providers available who can provide 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 the medical services provided on August 29, 2019 by out of network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve total knee arthroplasty surgery with out-of-network provider.
You asked the Plan to pre-approve total knee arthroplasty surgery. You say that the requested surgery with the out-of-network provider is medically necessary. The Plan denied your request. The Plan says the requested surgery with the out-of-network provider is not medically necessary and the enrollee can safely transition to an in-network provider for the surgery being requested.
Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet the enrollees' needs. The enrollee's contract with the Plan says that, with few exceptions, enrollees must use contract providers for care. 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 total knee arthroplasty surgery. Our reviewer says that the requested surgery with the out-of-network provider is not medically necessary and the enrollee can safely transition to an in-network provider for the surgery being requested. Our physician reviewer found the request is for total knee arthroplasty surgery with an out-of-network provider. The enrollee has been an established patient with the doctor since 2013. Based on the documentation provided, there is no need for an out of plan referral. The knee surgery may be safely performed in plan with a network provider. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of total knee arthroplasty surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve total knee arthroplasty surgery with out-of-network provider.