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

We decided that the Plan does not have to pay for the PET scan provided on February 5, 2020.
You asked the Plan to pay for the PET scan. The Plan denied your request. The Plan says the services were not billed with an appropriate diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that only certain diagnosis codes are appropriate when billing for a PET scan. We looked at the file and Medicare rules. The PET scan was billed with diagnosis codes C18.9 and C50.911. These codes are not listed as acceptable diagnosis codes for PET scans. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for the PET scan provided on February 5, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zolpidem ER tablets for the enrollee.You asked the Plan to pre-approve Zolpidem ER tablets. You say that this drug is medically necessary for the enrollee.The Plan denied your request. The Plan says this drug is 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 pre-approve Zolpidem ER tablets for the enrollee.Benefits for Zolpidem ER tabletsmay 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health services.You asked the Plan to pre-approve the inpatient mental health services. You say that the inpatient services are medically necessary.The Plan denied your request. The Plan says the enrollee's needs can be met at a lower level of care.The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment. 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 inpatient mental health services. Our reviewer says that inpatient level care is not medically necessary. Our physician reviewer found the admission of this enrollee does not meet the criteria for acute inpatient mental health treatment or inpatient detoxification as this enrollee was not shown to be a danger to himself or others, was without agitation or aggression, was without perceptual disturbance including auditory, visual hallucinations or delusions. The enrollee was not going through withdrawal symptoms.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 mental health services have not been met.Therefore, we decided that the Plan does not have to pre-approve inpatient mental health services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance services (HCPCS A0425 and HCPCS A0427) provided to the enrollee on December 29, 2019.You asked the Plan to pay for the services. You say that this should be paid for.The Plan denied your request. The Plan says a code is considered invalid if it has not been coded to the full number of digits required for that code.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 the denied codes is:HCPCS A0425:Ground mileage, per statute mile HCPCS A0427:Ambulance service, advanced life support, emergency transport, level 1 (als 1 -emergency) We asked our coding 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 services. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found based on the submitted information in this appeal, the claim was billed with diagnosis code G89.1 which was not coded at the highest level of specificity. ICD-9-CM Official Guideline for Coding and reporting states, "diagnosis codes are composed of 3 -5 digits. Code categories (3-digit codes) can be subdivided to provide greater detail by including a decimal and fourth or fifth digit. A 3-digit code is used only if the category is not further subdivided. When 4th-or 5th-digit classification is available they must be assigned. A code is considered invalid if it has not been coded to the full number of digits required for that code. One or more diagnosis codes submitted were not reported to the highest level of specificity available." Diagnosis G89.1 was not coded to its highest level of specificity, therefore the claim is not eligible for reimbursement. 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 ambulance services (HCPCS A0425 and HCPCS A0427) provided to the enrollee on December 29, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a knee scooter.
You asked the Plan to pre-approve a knee scooter. You say that a knee scooter is needed after surgery. The Plan denied your request. The Plan says the item is not a covered benefit under the plan.
The Plan must follow Medicare rules. Medicare rules say that canes and crutches are only covered under certain medical indications. We looked at the file and Medicare rules. In this case, there is insufficient evidence to show that a knee scooter is necessary above the standard cane or crutch. Based on this information, we decided that Medicare rules for coverage have not been met. Therefore, we decided that the Plan does not have to pre-approve a knee scooter.
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 have difficulty with bladder control due to your multiple sclerosis. You state that these pads are expensive and should be covered to help with this ongoing medical issue.The Plan denied your request. The Plan says Medicare does not provide coverage for incontinence supplies.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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical laparascopy (CPT 49652) provided to the enrollee on January 12, 2020.You asked the Plan to pay for the surgery. You say that this should be paid for.The Plan denied your request. The Plan says this code may not be billed with a laparascopic 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, the CPT Code Manual definition of code 49652 is "Laparoscopy, surgical, repair, ventral, umbilical, spigelian or epigastric hernia (includes mesh insertion, when performed)."We asked our coding 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 surgery. Our reviewer says that the services at issue in this case were not coded correctly. Our coding reviewer found CPT 47652 -Laparoscopy, surgical; cholecystectomy was the primary procedure performed on January 12, 2020. The National Correct Coding Initiative Policy Manual for Medicare Services 2017, Intro to Surgert: Digestive System E. Abdominal procedures no. 4 states "If a hernia repair is performed at the site of an incision for an open or laparoscopic abdominal procedure, the hernia repair is not separately reportable." For this reason, CPT 49652 is not eligible for reimbursement consideration. 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 surgery have not been met.Therefore, we decided that the Plan does not have to pay for surgical laparascopy (CPT 49652) provided to the enrollee on January 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammogram provided on February 7, 2020.You asked the Plan to pay for the mammogram. You say that the procedure was performed at the request of the referring doctor.The Plan denied your request. The Plan says the service was previously paid by the plan.The Plan must follow Medicare rules. Medicare rules say that payment may be made for only one screening mammography performed on a woman over age 34, but under age 40.We looked at the file and Medicare rules. The documentation shows that the enrollee received a screening mammogram on February 6, 2020, that was billed and paid for by the plan. The enrollee also received a screening mammogram on February 7, 2020. The rules say that only one screening mammography may be performed on a woman over age 34, but under age 40. Based on this information, we decided that Medicare rules for coverage of the mammogram have not been met. Therefore, we decided that the Plan does not have to pay for the screening mammogram provided on February 7, 2020.
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 this is medically necessary and should be approved
for payment. The Plan denied your request. The Plan says this does not meet the requirements for approval.
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 enrollee is medically stable and does not have complex medical issues that
require acute rehab nursing care, or monitoring by an inpatient rehabilitation physician three times per week.
While he may benefit from continuing PT and OT, there is no evidence of need for an intensive therapy
program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to
rehabilitation care.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.
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 this is medically necessary. The Plan denied your request. The Plan says rehab needs at present are not complex, and do not require an interdisciplinary approach with multiple specialists to oversee rehab 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 enrollee is medically stable and she does not have complex medical issues that require acute rehab nursing care, or monitoring by an inpatient rehabilitation physician three times per week. While she may benefit from continuing PT and OT, there is no evidence of need for an intensive therapy program with therapy 3 hours per day with frequent physician oversight and an interdisciplinary approach to rehabilitation care. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve 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 services provided on February 3, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing services provided on February 3, 2020.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for an electrocardiogram report (93010) provided on September 29, 2019.
You asked the Plan to pay for the electrocardiogram report. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says per the records, the interpretation was performed by a different provider than that billed on the claim.
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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. We find that CPT code 93010 is not supported in the record. Specifically, the record does not indicate that the provider who is billed on the claim rendered the service at issue. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram report have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram report (93010) provided on September 29, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on February 15, 2020.You asked the Plan to pay for. The Plan denied your request. The Plan says screening services are not covered.The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed above, are not covered.The lab services at issue in this appeal were requested solely for screening purposes. Medicare does not cover this testing solely for screening purposes.Therefore, we decided that the Plan does not have to pay for the lab services provided on February 15, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (CPT 72192) provided on January 12, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is included in the payment for another service.
The Plan must follow Medicare rules. Medicare rules say that if a provider reports the two codes of an edit pair, the column two code is denied, and the column one code is eligible for payment. Procedure code 72192 is part of an edit pair with procedure code 74177. Procedure code 74177 is a column one code, and procedure code 72192 is a column two code. Procedure code 74177 has been billed on this date of service, which means that procedure code 72192 is not eligible for payment. Therefore, we decided that the Plan does not have to pay for the services (CPT 72192) provided on January 12, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for positron emission tomography (PET) scan services provided on January 2, 2020.
You asked the Plan to pay for the PET scan. You say that the services were medically necessary to diagnosis and treat the enrollee. The Plan denied your request. The Plan says the PET scan in dispute was not reported with an appropriate diagnosis.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules say that PET procedures performed to inform the initial treatment strategy of tumors must be reported with an appropriate diagnosis. We find that coverage criteria for the PET scan is not supported in the medical record. Specifically, the PET scan was billed with diagnosis code C16.9. This diagnosis code is not listed as one of the diagnoses which allow for coverage of PET scans. Based on this information, we decided that Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not have to pay for positron emission tomography (PET) scan services provided on January 2, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a dental core build-up (D2950).
You asked the Plan to pre-approve the core build-up. You say that the core build-up is medically necessary. The Plan denied your request. The Plan says this service is not a covered benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve a dental core build-up (D2950).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) care for the enrollee.You asked the Plan to pre-approve the care. You say that this is medically necessary.The Plan denied your request. The Plan says Medicare does not cover custodial care or non-skilled care.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 ourphysician 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 care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.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 care have not been met.Therefore, we decided that the Plandoes not haveto pre-approvecontinued skilled nursing facility (SNF) care for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and two resin-based composites (D2335 x2) provided on February 3, 2020.
You asked the Plan to pay for the problem focused limited oral evaluation and resin-based composites. You say that the provider's office and were told that the services would be covered. You also say that you cannot afford to pay this amount. The Plan denied your request. The Plan says these services are not covered by the Plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the problem focused limited oral evaluation (D0140) and two resin-based composites (D2335 x2) provided on February 3, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home care services.You asked the Plan to pre-approve home care services. You say that you need assistance with activities of daily living.The Plan denied your request. The Plan says the requested services are custodial.The Plan must follow Medicare rules. Medicare rules say that custodial care is not covered. The rules also say that no provider or supplier shall receive payment for services furnished to a Medicare beneficiary unless the provider or supplier is enrolled in the Medicare program.We looked at the file and Medicare rules. The record shows that the requested services are for assistance with bathing, dressing, ambulating, transfers and using the bathroom.These services are custodial in nature. Furthermore, the provider you have requested to receive these services from is not enrolled in the Medicare program. Based on this information, we decided that Medicare rules for coverage of home care services have not been met.Therefore, we decided that the Plan does not have to pre-approve home care services.
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 this is medically necessary.The Plan denied your request. The Plan says care can received in another setting.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the records do not indicate that there are significant, or complex medical/nursing issues that could not be addressed at a SNF level of care. Ongoing pain medication and other medication management, wound care, and daily therapy can be provided at a SNF. A less intensive, longer duration of therapy will allow for measurable gains to be attained within a predicted period.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.