Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Partially Favorable

We decided that the Planhasto pre-approvebrachioplasty. We decided that the Plandoes not have to pre-approvethoracoplasty. You asked the Planto pre-approvebrachioplasty. You say thatthese services are medically necessary.The Plansaysthatthese services are cosmetic and not medically necessary.The Plans follows Medicare rules. The rules say that cosmetic surgery and related services, except as required for the prompt repair of accidental injury or to improve the functioning of a malformed body member, 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 brachioplasty. Our reviewer says that brachioplasty is medically necessary but thoracoplasty is not medically necessary at this time. Our physician reviewer found that you haveevidence of functional impairment related to excess soft tissue of botharms, as the result of severe weight loss following bariatric surgery. Yourfunctional impairment includes adverse effectson your shoulder range of motion and pain. This is supported by the requesting surgeon and physical medicine physician. No other conservative therapy would likely improve or resolve yourfunctional impairment. The requested procedure of brachioplasty would likely resolve or significantly improve yourfunctional impairment that is well-documented. This is supported by review of the photographs. This is not cosmetic surgery. It is unclear the additional need for thoracoplasty and thus this procedure is not supported by 
the medical documentation.We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of brachioplastyhavebeen met.We also decided that Medicare rules for coverage of thoracoplastyhavenotbeen met. Therefore, we decided that the Planhas topre-approve brachioplasty but does not have to pre-approvethoracoplasty
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded G0483 provided on April 9, 2019.
You asked the Plan to pay for the drug testing. 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 supported by the documentation.
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 drug test(s), definitive, utilizing (1) drug identification methods able to identify individual drugs and distinguish between structural isomers (but not necessarily stereoisomers), including, but not limited to gc/ms (any type, single or tandem) and lc/ms (any type, single or tandem and excluding immunoassays (e.g., ia, eia, elisa, emit, fpia) and enzymatic methods (e.g., alcohol dehydrogenase)), (2) stable isotope or other universally recognized internal standards in all samples (e.g., to control for matrix effects, interferences and variations in signal strength), and (3) method or drug-specific calibration and matrix-matched quality control material (e.g., to control for instrument variations and mass spectral drift); qualitative or quantitative, all sources, includes specimen validity testing, per day; 22 or more drug class(es), including metabolite(s) if performed. We find that CPT code G0483 is not supported in the medical record. Specifically, the documentation submitted did not include a valid physician order/lab requisition or medical records (signed by the ordering physician) for the billed test. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded G0483 provided on April 9, 2019.
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 7, 2019 to March 5, 2019 and billed under code S9328.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the code type used is not a covered benefit under Medicare and the plan. The Plan suggests the claim be resubmitted with a payable code per Medicare guidelines.
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, code S9328 has created errors on the claim preventing payment. Therefore, we decided that the Plan does not have to pay for home health services provided to the enrollee from February 7, 2019 to March 5, 2019 and billed under code S9328.
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 enrollee.You asked the Plan to pre-approve IRF care. You say that the services are medically necessary.The Plan denied your request. The Plan says the services are 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 services are not medically necessary. Our physician reviewer found the enrollee was admitted to the hospital on January 31, 2020 for treatment of weight loss, failure to thrive, and pneumonia. He also required treatment for constipation and protein-calorie malnutrition. As of February 10, 2020,he needs assistance with walking 35 feet with a rolling walker and transfers. He has no complex medical, nursing, or rehabilitation needs that require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. He may benefit from further therapy but does not require an intensive therapy program in an IRF.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 enrollee
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the complete series of periapical x-rays (D0210) provided on October 31, 2019.
You asked the Plan to pay for the dental service. You say that this service is part of your routine dental exam that you receive biannually. The Plan denied your request. The Plan says the complete series of periapical x-rays are covered once every 36 months. The Plan says the frequency limit has been exceeded. The Plan also says that you last received this service on November 9, 2016.
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 and the complete series of periapical x-rays is a covered service, the frequency limit has been exceeded. Therefore, we decided that the Plan does not have to pay for the complete series of periapical x-rays (D0210) provided on October 31, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services provided to the enrollee on August 21, 2019.
You asked the Plan to pay for this claim. You say that this service should be covered. The Plan denied your request. The Plan says the enrollee did not have prior authorization for 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 must 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 physician services provided to the enrollee on August 21, 2019.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay forthe chest x-ray rendered to the enrollee on July 19, 2019.You asked the Plan to pay forthese services. You say that you disagree with the denial.The Plan denied your request. The Plan says procedure code 71046 is not separately payable.The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.The provider submitted a claim for procedure codes 71046 and 77001. Code 71046 is a column II code with a modifier indicator of 1 when billed with column I code 77001. Code 71046 was not billed with an appropriate modifier to allow for separate payment.Therefore, we decided that the Plan does not have to pay forthe chest x-ray rendered to the enrollee on July 19, 2019.
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 the enrollee's medical condition is such that frequent physician supervision is needed and he would benefit from an intensive therapy program through which he could build up to three hours per day. The Plan denied your request. The Plan says the enrollee does not meet criteria for IRF 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 was admitted on 1/13/2020 due to leg pain caused by ischemia. He eventually required an above the knee amputation on 1/23. He also was suffering from rhabdomyolysis on admission. In PT on 2/3/20 he was total assist x 2 for supine to sit and dependent for support in sitting balance. He was fatigued after sitting at the edge of the bed for ten minutes. IRF was recommended and it was stated that the patient "may have to build up tolerating 3 hours." 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 documentation does not reveal that the patient's medical status requires the intensity of an IRF stay with close physician or nursing supervision. The patient may benefit and participate in additional therapy of PT and OT but the patient has fatigue and poor endurance and does not require this therapy on an intensive rehabilitation facility therapy program level in an IRF. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for train of four testing (95999) provided on January 18, 2019.
You asked the Plan to pay for the train of four testing. You say that the services rendered were medically
necessary. The Plan denied your request. The Plan says train of four is considered a bundled procedure and
payment for it is included in the payment for the already-approved neuromonitoring.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
We find that CPT code 95999 is not supported in the record. Specifically, train of four testing is considered
integral to the primary procedure and is therefore, part of the bundled payment. Based on this information, we
decided that Medicare rules for coverage of the train of four testing have not been met. Therefore, we decided
that the Plan does not have to pay for train of four testing (95999) provided on January 18, 2019.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care provided to the enrollee from January 12, 2019
through January 14, 2019.
You asked the Plan to pay for inpatient hospital care. You say that the claim should be paid. The Plan denied
your request. The Plan says that the stay is not medically necessary.
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 inpatient hospital care. Our physician
reviewer found the review has determined that the treating physician did document (in the physician notes, on a
form, or in an order) that the patient was not stable for transfer on any dates of service.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient hospital care have been met. Therefore, we decided that the Plan has to
pay for inpatient hospital care provided to the enrollee from January 12, 2019 through January 14, 2019.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the nursing facility care (99309, 99308) provided on January 2, 2019 to January 17, 2019
You asked the Plan to pay for nursing facility care. You say that these services were medically necessary and should be paid. The Plan denied your request. The Plan says these services were not authorized.
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 nursing facility care (99309, 99308) provided on January 2, 2019 to January 17, 2019
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the rhythm electrocardiogram coded 93042 provided on May 19, 2019.
You asked the Plan to pay for the rhythm electrocardiogram. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are bundled and not separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 93042 for the rhythm electrocardiogram has a bundled relationship with code 99291 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the rhythm electrocardiogram coded 93042 provided on May 19, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on April 3, 2019.
You asked the Plan to pay for lab tests. You say that you have submitted a valid physician laboratory requisition form. The Plan denied your request. The Plan says the denial of payment for these services is correct, because the documentation submitted does not support the Place of Service (POS) code billed on this claim.
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place where the sample was taken is reported as the Place of Service (POS). We looked at the file and Medicare rules. The record shows that the sample for this testing was taken in an office setting, therefore the Place of Service (POS) code 81 - indicating an independent laboratory place of service - is not appropriate for this claim. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on April 3, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approveacute inpatient rehabilitation facility (IRF) admission and services.You asked the Plan to pre-approveIRF care. You say that the services are necessary.The Plan denied your request. The Plan says based on the documentation provided, coverage criteria for IRF care has not been met.The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary asdescribed 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 isnot considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The documentation does not reveal that your medical status requires the intensity of an IRF stay with close physician or nursing supervision. You may benefit and participate in additional therapy of physical therapy (PT) and occupational therapy (OT) but you do not require this on an intensive rehabilitation facility therapy program level in an IRF.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-approveacute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Spiriva Respimat inhaler.
You asked the Plan to pre-approve the Spiriva inhaler. You say that this is needed. The Plan denied your request. The Plan says this self-administered inhaled medication is not covered by 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 the Spiriva Respimat inhaler.
Benefits for the Spiriva inhaler may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neuropsychological testing services (2 hours) for the enrollee.
You asked the Plan to pre-approve the testing. You say that this is medically necessary. The Plan denied your request. The Plan says a diagnosis of vascular dementia can be made without this testing.
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 the testing. Our reviewer says that the requested testing is not considered medically reasonable and necessary in this case. Our physician reviewer found it is noted that the provider is asking for this procedure be used to quantify this enrollee's cognitive profile for potential dementia or neurodegenerative disorder as she progresses through aging. The enrollee is believed to have vascular dementia. The enrollee does not meet the criteria for this testing, as she has no quantification of her memory impairment and over what length of time. The information provided is quite vague as this enrollee has not had a thorough clinical evaluation utilizing an evaluation of a mini mental status or global function. 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve neuropsychological testing services (2 hours) for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay forthe diazepam provided on September 27, 2019.You asked the Plan to pay forthis drug. The Plandenied your request. The Plan says that this is not covered by the Plan.The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B.Therefore, we decided that the Plan does not have to pay forthe diazepam provided on September 27, 2019.Benefits for this drugmay be available under Medicare Part D.Contactthe Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for laboratory services provided on August 8, 2019.
You asked the Plan to waive the copayment for laboratory services. You say that the cost for labs for your annual physical should be fully covered. You say that the services were performed by the lab at your primary care physician's office. The Plan denied your request. The Plan says the copayment applied 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 $45 copayment for lab services at an in-network outpatient hospital. You have been asked to pay $44.11, which is less than the standard $45 copayment for laboratory services. Laboratory services fall within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. Outpatient diagnostic tests are considered a separate service. 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 laboratory services provided on August 8, 2019.