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

We decided that the Plan does not have to pay for the neurostimulator implantation rendered on September 16, 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. The rules say that procedure codes describing anesthesia services (00100-01999) or services that are bundled into anesthesia should not be reported in addition to the surgical or medical procedure requiring the anesthesia services if performed by the same physician. The rules say that claims must be billed with the proper POS code. 

We looked at the file and Medicare rules. The file shows that procedure code 64555 (percutaneous implantation of neuroelectrodes) was billed as an anesthesia service. This code is not valid when billed as anesthesia. 

Billed procedure code L8679 (implantable neurostimulator, pulse generator, any type) was billed with place of service (POS) code 11 for an office. This is not an appropriate POS code for these services. 

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 neurostimulator implantation rendered on September 16, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for an inpatient admission provided from November 14, 2020, through November 21, 2020.

You asked the Plan to pay for the inpatient admission. The Plan denied your request. The Plan says the enrollee's emergency medical condition stabilized by 10:35 am on November 15, 2020, and subsequent care was post stabilization care, not approved in compliance with the health Plan's authorization procedures. The Plan has paid for all emergent care up to the point of stability. Inpatient care at a non-Plan Facility was not medically necessary to stabilize the enrollee.

The Plan must follow Medicare rules, which say that emergency care is covered. Plans must provide or pay for necessary post-stabilization care. When post-stabilization care is obtained from a non-contract provider, approval is required.

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 admission. Our reviewer says that the post stabilization care does not meet Medicare criteria. Our physician reviewer found that the enrollee is a 74-year-old female who was admitted to and treated in the hospital for chest pain. The enrollee's vitals were stable, and the electrocardiogram showed no signs of ischemia, but troponin was 0.311. She was given acetylsalicylic acid (aspirin), nitroglycerin with relief and pain levels went down to 1/10 in the emergency department. The enrollee's vitals and physical findings remained stable or normal. The records provided did not state that the enrollee was unstable at any time. Based on the records the enrollee appeared to be stable enough for transfer around 10:35 am on November 14, 2020.

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 admission have not been met. Therefore, we decided that the Plan does not have to pay for an inpatient admission provided from November 14, 2020, through
November 21, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital bed (E0251), mattress (E0271) and sales tax purchased on December 30, 2020.

You asked the Plan to pay for the hospital bed, mattress and sales tax. You say that you would like reconsideration for the equipment purchased. The Plan denied your request. The Plan says DME must be provided through a Medicare certified provider.

The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. 

Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. The record indicates that you were made aware of providers in your area who could offer your requested equipment. Additionally, Medicare contractors do not make additional payment for sales taxes. Therefore, we decided that the Plan does not have to pay for the hospital bed (E0251), mattress (E0271) and sales tax purchased on December 30, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on November 16, 2020.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says procedure code 64999 is not covered.

The Plan must follow Medicare rules. The rules say that CPT codes describing anesthesia services (00100-01999) or services that are bundled into anesthesia should not be reported in addition to the surgical or medical procedure requiring the anesthesia services if performed by the same physician. 

We looked at the file and Medicare rules. Billed procedure code 64999 (unlisted procedure, nervous system) was billed by an anesthesia practitioner. This code is not appropriate to bill for anesthesia services. Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on November 16, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided on April 5, 2021.
You asked the Plan to pay for anesthesia for intraoral procedures, including biopsy; not otherwise specified (00170). You say that the claim was billed with the appropriate diagnosis code so the Plan should pay this claim. The Plan denied your request. The Plan says the diagnosis code is not covered.
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 out-of-network anesthesia service is not allowed for this procedure. Therefore, we decided that the Plan does not have to pay for anesthesia services provided on April 5, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Synvisc-One for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is no indication that the preferred agents would be less effective than the requested agents.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires that these be trialed first. The documentation does not outline contraindications or reasons these medications were not considered. Without the support of the documentation, Synvisc-One is not approved, as step criteria have not been met. 

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Synvisc-One for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (90999) provided on January 1, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not billed correctly.

The Plan must follow Medicare rules. Medicare rules say that code 90999 must be billed with the appropriate G-modifier. 

We looked at the file and Medicare rules. In this case, code 90999 was billed without an appropriate G-modifier. 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 services (90999) provided on January 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to reimburse you the copayment for the specialist physician service provided on July 8, 2020
You asked the Plan to reimburse you the copayment for posterior tibial neurostimulation (64566). You say that the Plan should reimburse you for The Plan denied your request. The Plan says you were charged this copayment correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Physician services, Specialist's Office. You have been asked to pay a $40 copayment for posterior tibial neurostimulation (64566). The posterior tibial neurostimulation (64566) falls within the Physician services, Specialist's Office 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 reimburse you the copayment for the specialist physician service provided on July 8, 2020
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided on April 13, 2021.
You asked the Plan to pay for a full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit. You say that the service was necessary. The Plan denied your request. The Plan says the service at issue 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 pay for a full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided on April 13, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on January 13, 2021.
You asked the Plan to pay for ambulance service, basic life support, non-emergency transport. The Plan denied your request. The Plan says coverage will not be approved for routine transportation when no medical attention is required. The medical notes state that you are not bed confined and could be transported via car.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 ambulance service, basic life support, non-emergency transport. Our reviewer says that the ambulance service, basic life support, non-emergency transport was not medically reasonable and necessary. Our physician reviewer found that the medical records provided show that you had no symptoms of Coronavirus and you were in no distress at the time. You were not bed-confined, and it is documented that you could be transported via car. The documentation does not support that the another means of transport was contraindicated at the time of transport. The documentation does not support that you needed the expertise, services and lifesaving and life-sustaining equipment that only a
fully equipped ambulance can provide for safe transport on the date of transport. The documentation does not support that the ambulance transport was medically reasonable and 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 ambulance service, basic life support, non-emergency transport have not been met. Therefore, we decided that the Plan does not have to pay for ambulance service, basic life support, non-emergency transport provided on January 13, 2021.
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 you would be a risk at home for bed sores. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for COVID 19 pneumonia. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on September 17, 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 claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on September 17, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for home health services provided to the enrollee from February 2, 2021 to February 16, 2021.

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 corrected claim is needed.

The Plan must follow Medicare rules. Medicare rules say that home health services must be billed correctly. 

A review of the case file shows that the correct type of bill was not submitted in this case. 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 home health services provided to the enrollee from February 2, 2021 to February 16, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wig, any type, each (A9282) purchased March 2, 2021.
You asked the Plan to pay for the wig. You say that you have submitted this claim and was denied for a cranial prosthesis. You want an appeal and an explanation of what you need to do to get paid on this. The Plan denied your request. The Plan says this item is not covered.
Medicare may pay for items which either meet the definition of DME or a prosthesis when these items are ordered by a physician. The Plan follows these same rules. In this case, although the wig may be appropriate, it does not meet the definition of the above benefit categories. It is not considered DME because it does not directly treat a medical condition. It does not meet the Medicare definition of a prosthetic because it does not replace an internal body organ or attached tissue. As such, it is noncovered by Medicare. Furthermore, the Plan does not offer a supplemental benefit which would provide coverage for a wig. Therefore, we decided that the Plan does not have to pay for the wig, any type, each (A9282) purchased March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided on February 23, 2021.
You asked the Plan to pay for critical care services. You say that this was billed correctly. The Plan denied your request. The Plan says the time spent on this service was not documented.
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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. We find that CPT code 99291 is not supported in the medical record. Specifically, the submitted medical records do not include documentation of the time spent on critical care. Without this information, this code cannot be verified. Based on this information, we decided that Medicare rules for coverage of critical care
services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services (99291) provided on February 23, 2021.
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 for the enrollee.

You asked the Plan to pre-approve IRF care. You say that the member needs physical and occupational therapy 3 hours a day for 5 days. The Plan denied your request. The Plan says that the enrollee can safely receive the services the enrollee needs in other settings.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. 

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. 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 was admitted for respiratory failure and COVID 19 pneumonia. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 acute inpatient rehabilitation facility (IRF) admission and services for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to waive the cost-sharing for specialist office visit services and a Botox injection provided on July 2, 2020.

You asked the Plan to waive the cost-sharing for specialist office visit services and a Botox injection. You say that you were not made aware of your cost-sharing responsibilities and have now accumulated a high balance that you are not able to pay. The Plan denied your request. The Plan says the correct cost-sharing was applied.

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 20% coinsurance for Part B covered chemotherapy drugs and other Part B covered drugs and a $45 copayment for each specialist in-person office visit.

You have been asked to pay $233.61, or 20% of the Medicare-allowed charge of $1,168.05, for a Botox injection. You have also been asked to pay a $45 copayment for specialist office visit services. A Botox injection falls within the "Medicare Part B prescription drugs" benefit category. Specialist office visit services fall within the "Physician/Practitioner services, including doctor's office visits" 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 cost-sharing for specialist office visit services and a Botox injection provided on July 2, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services (99291) provided February 9, 2021.
You asked the Plan to pay for the critical care 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 99291 is critical care visit of 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not detail how
much time was spent on this service. Based on this information, we decided that Medicare rules for coverage of
the critical care services have not been met. Therefore, we decided that the Plan does not have to pay for
critical care services (99291) provided February 9, 2021.