Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (27702) provided May 28, 2020.

You asked the Plan to pay for the surgical services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim was not correctly billed.

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 code 27702 is not supported in the medical record. Specifically, a status indicator "C" inpatient procedure was billed on the outpatient claim. Based on this information, we decided that Medicare rules for coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (27702) provided May 28, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for hearing aids (V5298 x2) received on October 16, 2020.

You asked the Plan to pay for hearing aids. You say that you initially used the Plan's vendor, however because you waited too long, you canceled your order with them and went to an out-of-network provider. The Plan denied your request. The Plan says the items were received from a non-vendor provider and are not covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when the Plan vendor is used.

We looked at the file, and the Plan's rules. Based on this information, we decided that the Plan's rules for coverage of hearing aids have not been met. Specifically, the items were received from an out-of-network vendor and are not covered. Therefore, we decided that the Plan does not have to pay for hearing aids (V5298 x2) received on October 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.

You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.

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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to acute care hospital on 4/13/21 with septic shock secondary to pneumonia and urinary tract infection. Services in an LTACH must be medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. The enrollee must show signs and/or symptoms severe enough to need medical care. The services must be able to be furnished safely and effectively only on an inpatient basis. 

In this case, the enrollee is receiving acute care services at the current facility. The continued stay has not been denied. The LTACH does not provide services that are not available at the current level of care. The elements of the coverage rule are not satisfied. The requested service is not 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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH is not medically necessary.
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 admission to a LTACH is not medically necessary. Our physician reviewer found the enrollee was admitted to the current acute care facility with COVID pneumonia and acute respiratory distress syndrome requiring intubation, trach, and PEG. She was treated with antibiotics and diuresis. Weaning trials were initiated and the enrollee has been able to tolerate trach collar in the day and AC mod at night. The enrollee appears to be improving and is more stable but requires additional short term acute care services to further wean. Long term acute care does not appear to be needed. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Therefore, this request for LTACH services will be considered not medically necessary at this time. 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 long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve a CardioMEMS HF system.

You asked the Plan to pre-approve a CardioMEMS HF system. You say that the requested CardioMEMS HF system is medically necessary. The Plan denied your request. The Plan says that the requested CardioMEMS HF system is not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically 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 a CardioMEMS HF system. Our reviewer says that the requested CardioMEMS HF system is medically necessary. Our physician reviewer found the Food and Drug Administration has stated that that the CardioMEMS HF System is indicated for wirelessly measuring and monitoring pulmonary artery (PA) pressure and heart rate in New York Heart Association (NYHA) Class III heart failure patients who have been hospitalized for heart failure in the previous year. 

In this case, the record indicates in an outpatient note from March 2021 that the enrollee has NYHA class III heart failure. The enrollee was hospitalized in March 2021 for acute on chronic heart failure exacerbation. The elements of the approved indication for the device are satisfied. Sufficient literature exists to establish that the requested service is not experimental or investigational. "In routine clinical practice as in clinical trials, PA pressure-guided therapy for HF was associated with lower PA pressures, lower rates of HFH and all-cause hospitalization, and low rates of adverse events across a broad range of patients with symptomatic HF and prior HFH" Circulation: Heart Failure. 2020;13:e006863. The requested service is 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 a CardioMEMS HF system have been met. Therefore, we decided that the Plan has to pre-approve a CardioMEMS HF system.

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 Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the physical therapy services rendered on July 15, 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 claim was billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that therapy services must be billed with the GN, GO, or GP modifier. We looked at the file and Medicare rules. The file shows that procedure code 97140 (manual therapy techniques) was not billed with a required therapy modifier. 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 physical therapy services rendered on July 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 1, 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 codes 80157, 80177, 80201, 80162, 80159, and 80173 are 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.

We find that CPT codes 80157, 80177, 80201, 80162, 80159, and 80173 are not supported in the medical record. Specifically, the services are for blood serum testing and the records show that the services were performed on a urine sample. 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 laboratory services rendered on July 1, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on December 28, 2020.

You asked the Plan to pay an additional amount for the eyeglasses. The Plan denied your request. The Plan says the copay applied correctly to the claim based on your vision benefit.

Medicare generally does not cover routine vision and eyewear services. However, the Plan offers a routine vision and eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. The file shows that the Plan paid the correct amount based on the Plan's vision benefit. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on December 28, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided from June 16, 2019 through June 23, 2019 with the reported primary diagnosis A41.89, Other specified sepsis.
You asked the Plan to pay for the inpatient services provided from June 16, 2019 through June 23, 2019 with the reported primary diagnosis A41.89, other specified sepsis. The Plan denied your request. The Plan says there was insufficient objective clinical evidence to validate the diagnosis. The Plan sequenced diagnosis A04.71, Enterocolitis due to Clostridium difficile, as the principle diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with primary diagnosis code A41.89, other specified sepsis. 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 services provided from
June 16, 2019 through June 23, 2019 with the reported primary diagnosis A41.89, other specified sepsis. Our reviewer says that the documentation does not support that the inpatient care is payable as billed. Our physician reviewer found that the documentation indicates that the enrollee was a then a 76-year-old female who presented to the emergency room with abdominal pain and diarrhea. She was evaluated with laboratory studies and a CT of the abdomen/pelvis. The impression was colitis with a possibility of C dificile colitis. She was started on IV fluids, IV antibiotics and po Vancomycin and admitted. There was no clinical or laboratory evidence of sepsis. She had an elevated CRP and a lactic acid level of 2.6. She was not hypotensive and required no blood pressure support with fluids or vasopressor therapy. The review has determined that the primary diagnosis, A41.89 other specified sepsis was not supported by the medical records. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient services provided from June 16, 2019 through June 23, 2019 with the reported primary diagnosis A41.89, other specified sepsis.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for Otolaryngology services (92700) provided December 18, 2020.

You asked the Plan to pay for the Otolaryngology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

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 92700 is an unlisted otorhinolaryngological procedure. 

We find that CPT code 92700 is not supported in the medical record. Specifically, no detailed report was provided to describe the unlisted procedure that was billed. Based on this information, we decided that Medicare rules for coverage of the Otolaryngology services have not been met. Therefore, we decided that the Plan does not have to pay for Otolaryngology services (92700) provided December 18, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on October 25, 2020.
You asked the Plan to pay for the self-administered drugs. You say that these drugs were administered during an emergency room visit. You say that they should be covered. The Plan denied your request. The Plan says the drugs you received are considered self-administered. The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting on October 25, 2020.
Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room visit provided on November 14, 2020.

You asked the Plan to waive the copayment for emergency room visit. You say that the urgent care facility was closed, and you should only have to pay $45 for this visit. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $90 copayment for emergency room visit. 

You have been asked to pay $90 copayment for emergency room visit. Emergency room visit falls within the Emergency Care benefit category. 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 an emergency room visit provided on November 14, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services 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 the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that a SNF cannot be considered a residence for the
purpose of home health coverage.
We looked at the file and Medicare rules. The file shows that the enrollee was in a SNF for the billed date of
service. A SNF does not qualify as a residence for home health services coverage. Therefore, we decided that
the Plan does not have to pay for the home health services rendered on August 18, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a myoelectric prosthetic arm and hand.

You asked the Plan to pre-approve prosthetics. You say that the enrollee needs these prosthetics, and his
treating physician agrees with this plan of care. The Plan denied your request. The Plan says the denial of
authorization for these items is correct, because the enrollee could use a basic myoelectric prosthetic device and
the requested prosthetics are more than what is necessary for the enrollee.

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 prosthetics. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found these prosthetics exceed the enrollee's medical need. The medical records do not reveal that the
enrollee requires independently articulating digits and that he is unable to perform his mobility-related
activities of daily living (MRADLs) with a basic myoelectric device.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of prosthetics have not been met. Therefore, we decided that the Plan does not
have to pre-approve a myoelectric prosthetic arm and hand.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on February 27, 2020 by a non-participating 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-participating 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 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 the office visit provided on February 27, 2020 by a non-participating provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76770) provided on January 26, 2021.

You asked the Plan to pay for an ultrasound. You say that the enrollee had multiple exams. The Plan denied your request. The Plan says payment for this code is included in another procedure.

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, we have confirmed that code 76770 has a bundled relationship with code 93975 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an ultrasound (76770) provided on January 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87150, 87481, 87491, 87496, 87500, 87529, 87563, 87591, 87640, 87641, 87651, 87653, 87661, 87798, 87801) provided July 30, 2020.

You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.

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 87150, 87481, 87491, 87496, 87500, 87529, 87563, 87591, 87640, 87641, 87651, 87653, 87661, 87798, & 87801 are not supported in the medical record. Specifically, the place of service listed on the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). 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 lab services (87150, 87481, 87491, 87496, 87500, 87529, 87563, 87591, 87640, 87641, 87651, 87653, 87661, 87798, 87801) provided July 30, 2020.