Persius/hicric huggingface dataset:
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home health aide services.
You asked the Plan to pre-approve home health aide services. You say that you would like the plan to
reconsider their denial. The Plan denied your request. The Plan says the requested services are not medically
necessary.
The Plan must follow Medicare rules. The rules say that HHA services may be covered if it is medically
necessary for the enrollee to receive skilled nursing or therapy.
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 home health aide services. Our
reviewer says that the documentation does not support that the requested home health aide services are
medically reasonable or necessary. Our physician reviewer found you have possible Lewy-Body dementia
(LBD) and hallucinations. Your gait is steady. Your medications include Namenda, Remeron and Celexa. The
documentation does not support that you are home-confined. Therefore, the requested services are not a
covered benefit.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of home health aide services have not been met. Therefore, we decided that the
Plan does not have to pre-approve home health aide services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a referral to a tertiary-level urologist.You asked the Plan to pre-approve these services. You say that you would like to follow up with this provider.The Plan denied your request. The Plan says the tertiary level of care is not medically necessary.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 these services. Our reviewer says that the tertiary level of care is not medically necessary. Our physician reviewer found the submitted records show that you have prostate cancer and underwent a robotic prostatectomy surgery on June 8, 2015. A non-tertiary urologist is capable of routine follow-up with regards to prostate cancer without evidence of recurrence for over four years after robotic surgery. The referral 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 these services have not been met.Therefore, we decided that the Plan does not have to pre-approve a referral to a tertiary-level urologist.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the definitive drug testing.
You asked the Plan to pay for the testing services. You say that a urine drug screen is unplanned and intentionally random to accurately check for compliance. The Plan denied your request. The Plan says the documentation did not include a valid lab order or medical records stating exactly what tests are to be performed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code G0483 is definitive drug testing of 22 or more drug classes. We find that CPT code G0483 is not supported in the medical record. Specifically, there is no evidence that shows the test was individualized to identify 22 or more specific non-prescribed medications or illicit substances. The records provided do not document concerns based on clinical review and judgement. 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 pay for the definitive drug testing.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an admission for the SNF services.
You asked the Plan to pre-approve the SNF services. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for SNF admission.
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 medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications and IV antibiotics  for a wound infection (vancomycin). The enrollee had stable vital signs. She used oxygen via nasal cannula.
Regarding rehabilitation services, the enrollee received speech therapy (ST) and occupational therapy (OT) in the SNF. By the dates in question, the enrollee required varying assist with the activities of daily living. She tolerated a modified diet and thin liquids. Our physician reviewer found that the enrollee does require skilled nursing services. There are no identifiable skilled therapy service needs. It is not medically necessary and reasonable to provide skilled nursing or skilled 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve an admission for the SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided on July 18, 2019 by an out of network (OON) provider.
You asked the Plan to pay for the outpatient office services. You say that you would like reconsideration because the services rendered were medically necessary. The Plan denied your request. The Plan says utilization of network providers is required when possible and 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 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 July 18, 2019 by an out of network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services provided to the enrollee on January 3, 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 these codes are not valid for Medicare purposes.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that the denied codes are not supported in the medical record. Specifically, these codes have a status indicator of I according to the Medicare Physician's Fee Schedule. This indicates that the code is not valid for Medicare purposes. 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 lab services provided to the enrollee on January 3, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the insertion of an intervertebral biomechanical device (22854) and vertebral corpectomy (63081 and 63082) provided on October 28, 2019.
You asked the Plan to pay for the insertion of an intervertebral biomechanical device and vertebral corpectomy. You say that these codes are shown in the operative report. The Plan denied your request. The Plan says these codes 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. In this case, the CPT Code Manual definition of code 22854 is insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure); 63081 is vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment; and 63082 is vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, each additional segment (List separately in addition to code for primary procedure). 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 insertion of an intervertebral biomechanical device and vertebral corpectomy. Our reviewer says that these codes are not supported in the records. Our physician reviewer found the medical records provided do not include sufficient documentation to validate that a vertebral corpectomy (vertebral body resection), partial or complete, anterior approach with decompression of spinal cord and/or nerve root(s); cervical, single segment was performed on October 28, 2019. The clinical documentation to support billing 63081 must document the removal of at least half of the vertebral body. The documentation submitted does not include this in the operative note, therefore this service cannot be verified.
An add-on code is never eligible for payment if it is the only procedure reported by a practitioner." In this case, primary procedure 63081 cannot be validated and is not payable, therefore, 63082 and 22854 are not eligible for reimbursement. 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 insertion of an intervertebral biomechanical device and vertebral corpectomy have not been met. Therefore, we decided that the Plan does not have to pay for the insertion of an intervertebral biomechanical device (22854) and vertebral corpectomy (63081 and 63082) provided on October 28, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the bitewings (D0274).
You asked the Plan to pay for the bitewings. You say that you were told that the provider entered the wrong code for dental x-rays. You also say that you have never had to pay a copay or had x-ray services denied. The Plan denied your request. The Plan says this service is 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, bitewings (D0274) are not among those covered under this benefit. The contract clearly states that complete series of intraoral x-rays (D0210) and panoramic x-rays (D0330) are the only x-rays that are covered by your plan. Therefore, we decided that the Plan does not have to pay for the bitewings (D0274).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay fora cervical cancer screening (G0101) provided on November 25, 2019.You asked the Plan to pay fora cervical cancer screening. You say that you were told this would be covered.The Plan denied your request. The Plan says you have exceeded the frequency limitation on this service.The Plan must follow Medicare rules. Medicare rules say that when the beneficiary does not qualify for a more frequently performed screening Pap smear, contractors pay for the screening Pap smear only after at least 23 months have passed following the month during which the beneficiary received her last covered screening Pap smear.We looked at the file and Medicare rules. The records show that you previously had a screening pap test on November 11, 2018. 23 months had not passed since that month when you received the service at issue. Based on this information, we decided that Medicare rules for coverage of a cervical cancer screening have not been met.Therefore, we decided that the Plan does not have to pay fora cervical cancer screening (G0101) provided on November 25, 2019
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for facet joint injections (64495).
You asked the Plan to pay for the facet joint injections. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says that the documentation submitted 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 64495 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves
innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional
level(s) (List separately in addition to code for primary procedure) .
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 facet joint injections. Our reviewers says that CPT code
64495 meets criteria for billing or reimbursement consideration. Our reviewer found the medical records
document injections were performed bilaterally at L3-4, L4-5 and L5-S1. In total, 3 levels were injected
bilaterally. 64495 LT and 64495 RT would appropriately represent the third level.
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 facet joint injections have been met. Therefore, we decided that the Plan has
to pay for facet joint injections (64495).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient facility services provided on November 26, 2019. You asked the Plan to pay for the outpatient facility services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says this provider is Medicare certified as no active CMS Certification Number is on file.
The Plan must follow Medicare rules. Medicare rules 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. Based on this information, we decided that Medicare rules for coverage of the outpatient facility services have not been met. Therefore, we decided that the Plan does not have to pay for outpatient facility services provided on November 26, 2019.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the ultralightweight wheelchair and attachments provided to the enrollee on December 19, 2019.
You asked the Plan to pay for these items. The Plan denied your request. The Plan says that there is no itemized shipping/billing invoice.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery. The record shows that the Plan made several attempts to obtain the physician order and proof of delivery documentation for the items at issue in this appeal. The record does not contain a valid proof of delivery for the supplies provided in this case. Therefore, we decided that the Plan does not have to pay for the ultralightweight wheelchair and attachments provided to the enrollee on December 19, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a physician visit provided on January 15, 2018.
You asked the Plan to pay for physician visit. You say that you submitted the original claim in a timely manner. The Plan denied your request. The Plan says the denial of payment for this service is correct, because this claim was not submitted within the timely filing limit.
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 physician visit was not filed until April 18, 2019. 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 a physician visit provided on January 15, 2018.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for subsequent nursing facility care.
You asked the Plan to pay for the subsequent nursing facility care. The Plan denied your request. The Plan says
non-emergent, non-urgent services with out-of-network providers require 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 did not pre-approve the
services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we
decided that the Plan does not have to pay for subsequent nursing facility care.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for outpatient hospital services provided on March 21, 2019.You asked the Plan to waive the deductible for outpatient hospital services. You say that you disagree with the additional $1,000 charge.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that there is a $1,000 deductible for outpatient hospital services. You received outpatient hospital services on March 21, 2019. The record shows that you had paid $0 toward the $1,000 deductible prior to receiving the services. Therefore, you are responsible to pay the $1,000 deductible. The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient hospital services. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $1,000 deductible for outpatient hospital services. This cost sharing is a contractual obligation that had not been met at the time outpatient hospital services was received on March 21, 2019.Therefore, we decided that the Plan does not have to waive the deductible for outpatient hospital services provided on March 21, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services.
You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.
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 laboratory services.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for an Ambulance Transport (A0428, A0425) provided July 8, 2019.You asked the Plan to pay for the ambulance transport. You say that the service was medically necessary.The Plan denied your request. The Plan says Original Medicare is liable for payment.Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct the provider to bill Medicare directly for these services. The enrollee was under the Medicare hospice benefit for the dates of service at issue in this appeal.Therefore, we decided that the Plan does not have to pay for an Ambulance Transport (A0428, A0425) provided July 8, 2019.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the provided information indicates that the enrollee no longer requires daily 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 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 services. 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. You do not require skilled nursing or therapy services on a daily basis. You do 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued admission to a skilled nursing facility (SNF).