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

We decided that the Plan does not have to pre-approvea lower extremity prosthesis with accessories to be provided by an out of network (OON) provider.You asked the Plan to pre-approvea lower extremity prosthesis with accessories. You say that these services are medically necessary.The Plan denied your request. The Plan says that they have in network providers available.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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.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. We found no exception that would require the Plan to pre-approve these items/services.Therefore, we decided that the Plan does not have to pre-approvea lower extremity prosthesis with accessories to be provided by an out of network (OON) provider
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an extra battery.
You asked the Plan to pre-approve an extra battery. You say that you would like the Plan to reconsider their
denial. The Plan denied your request. The Plan says Medicare does not provide coverage for portable oxygen
concentrator batteries as the item itself. The portable oxygen concentrator can be recharged.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a
medical purpose.
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item 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-approve an extra battery.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on December 4, 2019, by an
out-of-network (OON) provider.
You asked the Plan to pay for these OON services. You say that you would like the plan to reconsider their
denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 December 4,
2019, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department visit provided on August 17,
2019.
You asked the Plan to pay for the emergency department visit. You say that the claim was originally filed
timely. The Plan denied your request. The Plan says the claim was untimely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for the emergency department visit was not filed until August 24, 2020. This
means that more than one calendar year from the date of service had passed before a claim was filed.
Therefore, we decided that the Plan does not have to pay for the emergency department visit provided on
August 17, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay formore than 30 minutes of hospital discharge day management services (99239) provided on June 29, 2020.You asked the Plan to pay forthe hospital discharge day management services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation does not support the service 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 99239 is hospital discharge day management; more than 30 minutes.We find that CPT code 99239 is not supported in the record. Specifically, the documentation does not indicate that more than 30 minutes of discharge day management services were rendered. Based on this information, we decided that Medicare rules for coverage of the hospital discharge day management services have not been met.Therefore, we decided that the Plan does not have to pay formore than 30 minutes of hospital discharge day management services (99239) provided on June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forBaclofen (J0475x17), Hydromorphone (J1170x66), Fentanyl Citrate (J3010x462) and unclassified (J3490x14) injectionsYou asked the Plan to pay forthe injections. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the documentation submitted does not support the number of units 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 asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the injections. Our reviewer says that the units billed for CPT codes J0475, J1170, J3490 and J3010 do not meet criteria for billing or reimbursement consideration. Our reviewer found 17 units of Baclofen were billed. The documentation submitteddoes not support the 17 units submitted for reimbursement consideration.  The medical records indicate .12 mg was administered which does not support the 170 mg that was billed.66 units of Hydromorphone were billed. The documentation submitted does not support the 66 units submitted for reimbursement consideration.  The medical records indicate 12 mg was administered which does not support the 264 that was billed.462 units of Fentanyl Citrate were billed. The documentation submitted does not support the 462 units submitted for reimbursement consideration. The medical records indicate 2.1 mg was administered which does not support the 46.2 mg that was billed.

14 units of unclassified drugs were billed. The documentation submitted does not support the 14units submitted for reimbursement consideration.  Only 1 unit on J3490 is appropriate to bill, therfore this service cannot be verified.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 injections have not been met.Therefore, we decided that the Plan does not have to pay forBaclofen (J0475x17), Hydromorphone (J1170x66), Fentanyl Citrate (J3010x462) and unclassified (J3490x14) injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied
your request. The Plan says the stay 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 SNF care. Our reviewer says that daily
skilled services are not necessary. Our physician reviewer found the member has stabilized medically and is
ready for discharge from the hospital. The member does not require skilled nursing and/or skilled therapy
services on a daily basis. The member is medically stable and can receive further rehab services at a lower level
of care. Although further rehab services would be appropriate to improve function, as a practical matter, the
daily skilled services can be provided at a lower level of care than a skilled nursing facility. The member does
not have any new parental medications to be given in the home; complex wound care or nutrition given via a
feeding tube. The member is medically stable without any acute exacerbations of chronic medical problems.
The member's physical function is at or near their baseline and she can receive services at a lower level of care.
Admission to a SNF for inpatient skilled rehab services is not medically necessary.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have
to pre-approve SNF care.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary.
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 based on the medical records provided the complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient does require physical therapy and occupational therapy services but based on the medical records provided the patient does not require an intensive inpatient rehabilitation therapy program. Based on the medical records provided there is no documentation that the patient requires the intensive rehabilitation therapy program provided in an IRF. Care at the skilled nursing facility level appears to be more appropriate in this case. 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 IRF admission and services.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the emergency room care services provided on March 27, 2020.
You asked the Plan to waive the copayment for the emergency room care services. You say that you believe this copayment should be waived based on the circumstances of the case. The Plan denied your request. The Plan says the copayment applied correctly in this case.
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 $90 copayment for emergency care. You have been asked to pay a $90 copayment for the emergency room care services. The services provided fall 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 the emergency room care services provided on March 27, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe knee orthosis (L1833) and suspension sleeve (L2397) provided on July 9, 2020.You asked the Plan to pay forthe knee orthoses. You say that you would like reconsideration because the member should be able to choose the physician that evaluates them for pain management.The Plan denied your request. The Plan says the member's claim history does not support the medical records provided.The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the knee orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of recent injury to, or recent surgical procedure on, the enrollee's knee, and there is insufficient credible objective documentation of joint laxity. 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 knee orthoses have not been met.Therefore, we decided that the Plan does not have to pay forthe knee orthosis (L1833) and suspension sleeve (L2397)provided on July 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forinjection services (J3490) provided to the enrollee on May 14, 2020.You asked the Plan to pay forthe services. You say that this should be paid for.The Plan denied your request. The Plan says the documentation submitted indicate that nutria-pharmaceutical blend was administered; therefore, each component of the blend cannot be billed separately.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 HCPCS code J3490 is "unclassified drugs."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 atissue in this case were not supported by the medical records. Our coding reviewer found the medical records submitted include documentation that a nutria-pharmaceutical blend was injected, therefore, it is not appropriate to bill these drugs separately for reimbursement consideration. Medicare says HCPCS code J7999 -compounded drug, not otherwise classified should be used to report this service.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 forinjection services (J3490) provided to the enrollee on May 14, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plandoes not haveto pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Planto pre-approveIRF care. You say that this is medically necessary.The Plandenied your request. The Plansaysthe services can be safely received in a different setting, for example: a skilled nursing facility, residential long term care with outpatient therapy, or home with home health therapy.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described above.We asked our physician reviewer to carefully review the case file and applythe 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 physicianreviewer found based on the medical records provided, 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 does not require an intensive inpatient rehabilitation therapy program. Care at the skilled nursing facility level or in the home with home health services appears to be more appropriate in this case.We looked at this physician's review, the file, and Medicarerules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met.Therefore, we decided that the Plandoes not haveto 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-approvelong term acute care hospital (LTACH) services for the enrollee.You asked the Plan to pre-approvethe LTACH services. You say that these services are medically necessary.The Plan denied your request. The Plan says that the records show that due to the enrollee's extensive brain injury and no improvement, the doctor feels hospice is appropriate.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. The enrollee still requires acute hospital level of care services and is receiving appropriate care at the present acute care facility. The enrollee does not require services at the LTACH that are not available at the acute care hospital where he is currently receiving care. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH services.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-approvelong term acute care hospital (LTACH) services for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe services (CPT 69209) provided on May 17, 2020.You asked the Plan to pay forthe services. The Plan denied your request. The Plan says this service is not payable.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Medicare rules also say that codes with a PC/TC indicator of 5 are not payable for hospital inpatients or patient in the outpatient department.          We find that CPT code 69209 is not supported in the medical record. Specifically, the PC/TC indicator for this code is 5, which means payment cannot be made when these services are provided to hospital inpatients or patients in the outpatient department. 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 forthe services (CPT 69209) provided on May 17, 2020.
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 need the shower chair but cannot pay for
it. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forstimulus evoked response, or measurement of bulbocavernosus reflex latency time (51792) provided March 4, 2020.You asked the Plan to pay forthe stimulus evoked response. You say that your office was unaware that medical records were needed until May 2, 2020. You are asking for reconsideration of these claims for payment.The Plan denied your request. The Plan says the records do not support the billed service.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 51792 is stimulus evoked response, or measurement of bulbocavernosus reflex latency time.We find that CPT code 51792 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of stimulus evoked response was performed. The plan made multiple attempts to obtain the additional information from the provider without success. Based on this information, we decided that Medicare rules for coverage of the stimulus evoked response have not been met.Therefore, we decided that the Plan does not have to pay forstimulus evoked response, or measurement of bulbocavernosus reflex latency time (51792) provided March 4, 2020
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for monitored anesthesia care provided to the enrollee on
November 26, 2019.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your
request. The Plan says the anesthesiologist did not provide information to substantiate the use of monitored
anesthesia care in this case.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically
necessary are not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the
requested services are not considered medically reasonable and necessary in this case. Our physician reviewer
found the review has determined that the documentation did not clearly establish a need for monitored
anesthesia care in this case. The clinical records provided did not support for at least an ASA 3 indicator for
this enrollee. There was no documentation as to enrollee's condition that warranted the P3 modifier or the
overall medical necessity for the need of monitored anesthesia 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 services have not been met. Therefore, we decided that the Plan does not
have to pay for monitored anesthesia care provided to the enrollee on November 26, 2019.