Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve incontinence supplies. 
 
You asked the Plan to pre-approve incontinence supplies. You say that you are in urgent need for these 
supplies. The Plan denied your request. The Plan says this item is not a covered benefit. 
 
The Plan covers all items that Medicare covers. Medicare rules state that incontinence supplies are not covered 
because they are hygienic items that are non-reusable.  
 
While incontinence supplies may be appropriate in this case, neither the Plan nor Medicare offers coverage of 
these items. Therefore, we decided that the Plan does not have to pre-approve incontinence supplies.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance services provided on July 21, 2020. 
 
You asked the Plan to pay for the ambulance services. You say that you were treated in place by the medics. 
The Plan denied your request. The Plan says these services are not a covered benefit. 
 
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when 
there is no transport.  
 
The ambulance company did not provide transport services on July 21, 2020. The ambulance benefit is a 
transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 
Therefore, we decided that the Plan does not have to pay for the ambulance services provided on July 21, 2020.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Mohs micrographic technique services coded 17311 and 
17312, the surgical trays coded A4550, and the full thickness graft services coded 15260 provided. 
 
You asked the Plan to pay for the Mohs micrographic technique services, the surgical trays , and the full 
thickness graft services. 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 payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT codes 17311, 17312, A4550, and 15260 are not supported in the medical record. Specifically, 
code 15260 was billed with modifier 79. Any procedures appended with modifier 79 when the same or 
different 0, 10 or 90-day procedure code has not been billed on the same day for a code with a 0-day post-
operative period, on the same day or in the previous 10 days for a code with a 10-day post-operative period, or 
on the same day or in the previous 90 days for a code with a 90-day post- operative period. 
code 15260 -79 was reported on claim # 820193460002369 with the same Tax ID and specialty for date of 
service 12/3/2019. The claim was processed on 12/14/2019 and code 15260 was denied by DP 10086 as there 
is no other surgical procedure identified in the past 90 days. 
 
In addition, claim ID 820200070003149 reported with codes 17311 (Mohs micrographic technique, 1st stage) 
and 17312 (Mohs micrographic technique, additional stage) billed for DOS 12/30/2019 and claim ID 
820193460002312 reported with codes 17311 and 17312 could not be used as a prior
 
 
surgery as the global day codes are 0 and ZZZ. Payment for A4450, the surgical trays is a bundled code; 
therefore, payment for covered services are always bundled into payment for other services. 
 
Based on this information, we decided that Medicare rules for coverage of the Mohs micrographic technique 
services, the surgical trays, and the full thickness graft services have not been met. Therefore, we decided that 
the Plan does not have to pay for the Mohs micrographic technique services coded 17311 and 17312, the 
surgical trays coded A4550, and the full thickness graft services coded 15260 provided.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the voiding pressure studies, intra-abdominal services coded 
51797 provided on February 20, 2020. 
 
You asked the Plan to pay for the voiding pressure studies, intra-abdominal services. 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 
payable. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
In this case, the CPT Code Manual definition of code 51797 is oiding pressure studies, intra-abdominal (ie, 
rectal, gastric, intraperitoneal) (List separately in addition to code for primary procedure). 
 
We find that CPT code 51797 is not supported in the medical record. Specifically, this was billed with modifier 
51 (multiple surgeries/procedures). This code has a status code of "A". A status code of A means that these 
codes are separately paid under the physician fee schedule if covered. No payment adjustment rules apply. If 
the procedure is reported on the same day as another procedure, the procedure is paid at the lower of the actual 
charge or the fee schedule amount for the procedure. Modifier 51 is not needed on this code. Based on this 
information, we decided that Medicare rules for coverage of the voiding pressure studies, intra-abdominal 
services have not been met. Therefore, we decided that the Plan does not have to pay for the voiding pressure 
studies, intra-abdominal services coded 51797 provided on February 20, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approveskilled nursing facility (SNF) services.You asked the Plan to pre-approvethe SNF services. You say that the enrollee requires SNF care for her condition. You say that the enrollee was also diagnosed with COVID-19 and is unable to bear weight on her legs.The Plan denied your request. The Plan says SNF care is not medically necessary.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 the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, had no pain, and was alert with confusion. The enrollee received physical therapy and occupational therapy in the acute hospital. The enrollee was at maximal assist level with functional mobility. The enrollee required varying assist with activities of daily living. There are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting.Welooked 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-approveskilled nursing facility (SNF) services.
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 the enrollee is progressing from the current hospital and is ready for transfer to a rehab in order to regain his maximum function.The Plan denied your request. The Plan says the guidelines for coverage of care in an IRF 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 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 lumbar spine surgery. The enrollee's 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, 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 the 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-approveacute inpatient rehabilitation facility (IRF) admission and services.
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 the enrollee needs help from a rehab center because of his condition and in order to be safe from COVID-19.The Plan denied your request. The Plan says the guidelines for coverage of 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 andapply 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 enrollee does not require the intensity of services provided at an IRF.  Specifically, the enrollee is not shown to be able to currently tolerate fifteen hours per week of rehabilitative services with regular physician evaluation.The enrollee's care needs can be met 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 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: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a shower chair. 
 
You asked the Plan to pre-approve a shower chair. You say that you have fallen out of the shower and this 
request is for safety purposes for your hygiene. The Plan denied your request. The Plan says this item is not a 
covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are 
not primarily medical in nature.  
 
While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this 
item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the lumbar-sacral orthosis rendered. 
 
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 there is no valid proof of delivery. 
 
The Plan must follow Medicare rules. The Plan must follow Medicare rules. The rules say that all DMEPOS 
suppliers are required to maintain proof of delivery. 
 
We looked at the file and Medicare rules. There is no valid proof of delivery in the documentation. 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 lumbar-sacral orthosis rendered.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the new patient office visit rendered on August 18, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says procedure code 99203 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 99203 is new patient office or other outpatient visit, 
typically 30 minutes. 
 
We find that CPT code 99203 is not supported in the medical record. Specifically, the file shows that the 
enrollee was seen by the same provider on July 9, 2019; therefore, the new patient description does not apply. 
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 new patient office visit rendered on August 18, 
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay forthe medical services provided on June 2, 2020, by an OON provider.You asked the Plan to pay forlaboratory testing. You say that you have executed your due diligence to abide by the Plan's parameters.The Plan denied your request. The Plan says rules for payment have not been met.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 forthe medical services provided on June 2, 2020, by an OON provider.Your complaint about the Plan refusing to cover OON services after providing coverage for one and a half yearsis not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approvepanniculectomy surgery.You asked the Plan to pre-approvepanniculectomy. You say that you are appealing.The Plan denied your request. The Plan says the denial of authorization for this service is correct, because there is no information showing that you have had skin infections from extra skin that have lasted more than 3 months despite treatment.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 pre-approve panniculectomy. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found you have undergone significant weight loss and are noted to have excess tissue of the lower abdomen. A clear functional deficit related to this excess, overlapping skin of the abdomen was not documented. As a well-defined functional deficit related to the excess tissue has not been clearly documented, the planned panniculectomy procedure does not satisfy Medicare coverage criteria.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of panniculectomy have not been met.Therefore, we decided that the Plan does not have to pre-approvepanniculectomy surgery
Appeal type: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve additional routine transportation. 
 
You asked the Plan to pre-approve additional routine transportation. You say that you would like the Plan to 
reconsider their denial. The Plan denied your request. The Plan says you are covered for up to 60 one-way trips 
per calendar year. The Plan says you have 1 one-way trip remaining and you will have reached your benefit 
limit for the year. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan?s coverage rules apply in this 
case. The Plan covers a maximum of 60 one-way transportation trips per year.  
 
We looked at your request, the records in the case file, and the rules. The file shows that you have used 59 of 
the 60 allotted one-way trips for the year. You have 1 one-way trip remaining and you will have reached your 
benefit limit for this year. Therefore, we decided that the Plan does not have to pre-approve additional routine 
transportation.
Appeal type: Inpatient Hospital
Decision: Favorable

 
We decided that the Plan has to pay for the acute inpatient hospital care provided to the enrollee from February 
5, 2020 to February 13, 2020. 
 
You asked the Plan to pay for the acute inpatient hospital care. You say that these services were medically 
necessary. The Plan denied your request. The Plan says that that the participant's care needs could have been 
provided in an alternative care level such as observation status or acute nursing facility. 
 
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor 
expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, 
consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or 
more. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pay for the acute inpatient hospital care. Our 
reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. The 
record showed that at the time of inpatient admission the admitting physician reasonably expected that the 
patient's necessary hospital care (including earlier emergency department and/or observation care) would span 
two midnights. Our physician reviewer found that the enrollee's condition met Medicare criteria for the acute 
inpatient hospital 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 the acute inpatient hospital care have been met. Therefore, we decided that the 
 
 
Plan has to pay for the acute inpatient hospital care provided to the enrollee from February 5, 2020 to February 
13, 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 debridement services rendered on June 9, 2020. 
 
You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your 
request. The Plan says the services are not covered. 
 
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 11042 is 1. You billed 2 units of this code, exceeding the MUE. 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 debridement services rendered on June 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use (CPT Code 90707) and immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) (90471) provided on July 29, 2020.
You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the services. The Plan follows the same rules. Records do not show that you have been injured or directly exposed to any illness related to the services. Measles, mumps and rubella virus vaccine (MMR) vaccine is not covered as a preventative service by Medicare after the age of 18 years.
Therefore, we decided that the Plan does not have to pay for measles, mumps and rubella virus vaccine (MMR), live, for subcutaneous use (CPT Code 90707) and immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) (90471) provided on July 29, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ER visit provided on June 2, 2020.
You asked the Plan to waive the copayment for the ER visit. The Plan denied your request. The Plan says the copayment applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $50 copayment for emergency care. You have been asked to pay a $50 copayment for the ER visit. The ER visit falls within the "Emergency care" benefit category. The records show that you were treated in the ER. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for the ER visit provided on June 2, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approvehome modifications.You asked the Plan to pre-approvehome modifications. You say that the previous modifications you had made an existing leakage problem worse.The Plan denied your request. The Plan says the denial of authorization for home modifications is correct, because home modification is of general utility and is not of direct or remedial medicalbenefit.The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose.  The home modifications at issue in this appeal do not serve a purpose that is primarily medical in nature. Home modification is available to the general public and would be helpful even to those who are not sick or injured.Therefore, we decided that the Plan does not have to pre-approvehome modifications.