Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital care provided from July 20, 2020, through July 22, 2020 billed with principal diagnosis code A41.9.
You asked the Plan to pay for the inpatient hospital care as billed. You say that this was billed correctly. The Plan denied your request. The Plan says this DRG was reduced as sepsis was not shown to be the principal diagnosis for this admission. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with principal diagnosis code, A41.9, defined as Sepsis, unspecified organism. 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 hospital care as billed. Our reviewer says that the documentation does not support A41.9 as the principal diagnosis for this admission. Our physician reviewer found the enrollee presented with progressive right upper quadrant abdominal pain. His temperature was 102 but he was hemodynamically stable. He was pan-cultured and started on Rocephin and Azithromycin. A computed tomography (CT) scan of the abdomen showed acute cholecystitis with ascending cholangitis. He underwent cholecystectomy and was discharged the next day in stable condition. The review has determined that there was no evidence of sepsis per the medical records. As such, A41.9 is not supported as the principal diagnosis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital care provided from July 20, 2020, through July 22, 2020 billed with principal diagnosis code A41.9.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 13, 2020.
You asked the Plan to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device. You say that the treatment was medically necessary and should be covered. The Plan denied your request. The Plan says the record does not support that the procedures were performed as 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 HCPCS/CPT Code Manual definition of code 97016 is application of blood vessel compression or decompression device to 1 or more areas. The HCPCS/CPT Code Manual definition of code 97032 is application of a modality to 1 or more areas; electrical stimulation (manual), each 15 minutes. The HCPCS/CPT Code Manual definition of code 97150 is therapeutic procedure(s), group (2 or more individuals). The HCPCS/CPT Code Manual definition of code 96372 is therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular. The HCPCS/CPT Code Manual definition of code J3490 is unclassified drug injection. The HCPCS/CPT Code Manual definition of code J3411 is injection, thiamine hcl, 100 mg. The HCPCS/CPT Code Manual definition of code J3415 is injection, pyridoxine hcl, 100 mg. We find that HCPCS/CPT codes 97016, 97032, and 97150 are not supported in the medical record. Specifically, the record does not support that a blood vessel compression device was applied. The manufacturer of the Sanexas device describes it as an electric cell signaling energy wave device, which does not meet the criteria to report CPT code 97016. The record also does not support that manual electrical stimulation was applied to any area for any amount of time. The record states that the Sanexas device was applied using standard programs. This does not support constant direct patient contact, which is required to report CPT code 97032. The record also does not support that therapeutic procedures in a group of 2 or more was performed. The record does not mention any therapeutic procedures, or the presence of any other patients receiving therapy at the same time; the criteria for reporting CPT code 97150 has not been met. Payment for HCPCS/CPT codes 96372, J3490, J3411, and J3415 are not supported. Specifically, the record does not contain documentation of the dosage and type of drug administered in each injection, which is required by Medicare for these services to be reimbursed. Based on this information, we decided that Medicare rules for coverage of the nutria-pharmaceutical injections and treatment with a Sanexas device have not been met. Therefore, we decided that the Plan does not have to pay for the nutria-pharmaceutical injections and treatment with a Sanexas device reported on August 13, 2020.
Appeal type: ER
Decision: Favorable

We decided that the Plan has to pay for the emergency department visit (99283) and after-hours services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (99053) provided December 20, 2020.

You asked the Plan to pay for the emergency visit. You say that you woke up at 3 am to find your top lip was swollen up to your nose and a very hard lump in it. You didn't want to wait until your breathing was affected. The ER was the only place you could go at the time. The Plan denied your request. The Plan says that the diagnosis of K04.7 (Periapical abscess without sinus) is not covered by the plan.

The Plan must follow Medicare rules. Medicare rules say that Medicare rules say that this PFFS (private fee for service) plan will generally cover your medical care as long as the care you receive is considered medically necessary and you receive your care from a provider who is eligible to provide services under Original Medicare or eligible to be paid by the Plan for benefits that are not covered under Original Medicare. 

We looked at the file and Medicare rules. The health plan contract says that if you need emergency care, it is covered whether a provider agrees to accept the plan's payment terms or not. The health plan contract does not say that if the emergency room bills a claim that is not Medicare appropriate, the enrollee would have knowledge of that giving prior notice of non-coverage. Based on this information, we decided that Medicare rules for coverage of the emergency visit have been met. Therefore, we decided that the Plan has to pay for the emergency department visit (99283) and after-hours services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (99053) provided December 20, 2020.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Tecentriq.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 services are not medically necessary. Our physician reviewer found the enrollee has poorly-differentiated non-small cell lung cancer (NSCLC). Tecentriq is FDA-approved as first-line treatment (in combination with paclitaxel [protein bound] and carboplatin) of metastatic nonsquamous NSCLC in adults with no EGFR or ALK genomic tumor aberrations. There is no documentation of EGFR or ALK status for this enrollee; therefore, Tecentriq 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 Tecentriq.
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 records provided support the need for care in an IRF. The Plan denied your request. The Plan says IRF care 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 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. Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for congestive heart failure. The enrollee's medical conditions are stable.
There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. The enrollee does require physical and occupational therapy but there is no documented need for an intensive rehabilitation program. Medically necessary services can be provided in a different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (76882) provided November 20, 2020.
You asked the Plan to pay for the ultrasound. You say that the services were medically necessary. The Plan
denied your request. The Plan says payment for this service was bundled in payment for another 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, we have confirmed that code 76882
has a Column I / Column II with code 76642 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 an ultrasound (76882) provided November 20, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Flexitouch System.
You asked the Plan to pre-approve the Flexitouch system. You say that you would like reconsideration because this device is medically necessary. The Plan denied your request. The Plan says you do not meet Medicare coverage criteria for the requested equipment.
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 Flexitouch system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the records do not document a trial and failure of 4 weeks of a basic pneumatic compression device (E0651). 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 Flexitouch system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Flexitouch System.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression (0275T).
You asked the Plan to pre-approve this service. You say that this service is medically necessary for the enrollee. The Plan denied your request. The Plan says the enrollee does not meet Medicare criteria for coverage of this procedure as they are not enrolled in a clinical study.
The Plan must follow Medicare rules. Medicare rules say that PILD will be covered by Medicare when provided in a clinical study under section 1862(a)(1)(E) of the Social Security Act (the Act)through Coverage with Evidence Development (CED) for beneficiaries with LSS who are enrolled in an approved clinical study that meets additional criteria. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of this service have not been met. Specifically, Medicare rules say that this service is covered when provided in a clinical study. The documentation provided does not indicate that the member is enrolled in a clinical study at this time. Therefore, we decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression (0275T).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an Absolute Quantification Myocardial Perfusion PET scan for the enrollee.
You asked the Plan to pre-approve the scan. You say that this is medically necessary. The Plan denied your request. The Plan says this is not medically necessary.
The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary. 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 scan. Our reviewer says that the requested services are not medically reasonable or necessary. Our physician reviewer found the request made is for a special type of PET myocardial perfusion scan know as AQMBF. This type of scan is considered experimental.
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 scan have not been met. Therefore, we decided that the Plan does not have to pre-approve an Absolute Quantification Myocardial Perfusion PET scan for the enrollee.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued PT visits.
You asked the Plan to pre-approve continued PT visits. You say that you have made considerable improvement and had to use your cane 100% of the time previously; however, after therapy you use your cane less. The Plan denied your request. The Plan says the exercises should be continued on your own or with the help of non-therapists.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 continued PT visits. Our reviewer says
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health Plan. You have had extensive prior therapy and the medical records do not demonstrate significant functional deficits that require the unique skills of a professional therapist to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continued PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve continued PT visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the neuromuscular stimulator, electronic shock unit (E0745) provided August 31, 2020.
You asked the Plan to pay for the electronic shock unit. You say that the medical records provided should support the necessity of the service in dispute. The Plan denied your request. The Plan says the records do not support the billed service.
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 does not contain proof of delivery and did not include an itemized shipping/billing invoice to indicate the specific supplies. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for the neuromuscular stimulator, electronic shock unit (E0745) provided August 31, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory testing provided on November 10, 2020 by an out of network (OON) provider.
You asked the Plan to pay for lab tests. You say that you performed the tests ordered by the referring physician in good faith. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this provider is out-of-network with the Plan and the ordering physician is also out-of-network with the Plan. 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 had network providers available who could have provided 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 laboratory testing provided on November 10, 2020 by an out of network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from January 4, 2021, through January 5, 2021.
You asked the Plan to waive the copayment for the inpatient stay. You say that the pictures taken did not show the bleeding in your stomach. You say that you are appealing the denial of medical services you received as an inpatient. 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 $175 copayment per day, days 1 to 5 at an in-network inpatient hospital.
You have been asked to pay a $175 copayment for the inpatient stay. The inpatient stay falls within the "Inpatient hospital 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 inpatient stay provided from January 4, 2021, through January 5, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit to be provided by an out of network
(OON) provider.
You asked the Plan to pre-approve the office visit. You say that due to the nature of your condition, you want a
second opinion. You say you would prefer to see an out-of-network doctor. The Plan denied your request. The
Plan says the provider is out-of-network.
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-approve
the office visit to be provided by an out of network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the remote pacemaker check to be provided by an out of network (OON) provider.
You asked the Plan to pre-approve the remote pacemaker check. You say that you are requesting continuity of care for the pacemaker follow-up. You say you are unable to go into the office due to Covid-19. The Plan denied your request. The Plan says the provider is out-of-network.
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-approve the remote pacemaker check to be provided by an out of network (OON) provider.