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

We decided that the Plan does not have to pre-approve 5 additional home health skilled nursing visits.

You asked the Plan to pre-approve 5 additional home health skilled nursing visits. You say that home health skilled nursing care is not medically necessary. The Plan denied your request. The Plan says the criteria for home health skilled nursing care have not been met.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

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 5 additional home health skilled nursing visits. Our reviewer says that the requested home health skilled nursing care is not medically necessary. Our physician reviewer found the enrollee does not have documented skilled nursing needs (e.g. IVs, complex wound care, new/frequent medication changes). As such, the requested, ongoing, home health skilled nursing services are not shown to be medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 5 additional home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 5 additional home health skilled nursing visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95886), nerve conduction studies (95908), and neuromuscular junction testing (95937) provided on January 14, 2021.
You asked the Plan to pay for needle electromyography, nerve conduction studies, and neuromuscular junction testing. You say that all billed codes were necessary. The Plan denied your request. The Plan says these codes were 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. 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 needle electromyography, nerve conduction studies, and neuromuscular junction testing. Our reviewer says that these codes are not supported. Our reviewer found the documentation supports pedicle screw testing, which should not be reported with CPT 95908. CPT 95886
includes nerve conduction studies, which are not documented in the technical report. The technical report also does not document neuromuscular junction testing, meaning 95937 cannot be confirmed as performed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of needle electromyography, nerve conduction studies, and neuromuscular junction testing have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95886), nerve conduction studies (95908), and neuromuscular junction testing (95937) provided on January 14, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76604, 76705, 76775) provided on November 29, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of codes 76604, 76705, and 76775 is not supported by the records provided. Our reviewer found that these were billed for date of service November 29, 2020, however, documentation submitted documents the results of procedures were provided on December 02, 2020. Therefore, these procedures cannot be confirmed as provided on the billed
date of service. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (76604, 76705, 76775) provided on November 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 22, 2021, through June 23, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that you needed oxygen and could not leave the hospital until you received the oxygen. The Plan denied your request. The Plan says the medical records show you were observed overnight with a 16 hour stay and were deemed stable for discharge home with new medication and oxygen.

The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 

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 acute inpatient hospital care. Our reviewer says that the acute inpatient hospital care was not medically necessary. Our physician reviewer found you presented to the emergency department (ED) with right eye irritation, redness, and swelling after accidentally scratching your eye. You were short of breath in the ED and your blood oxygen was 85% on room air and improved to 95% on supplemental oxygen. You did not report fever or have a history of recent illness or worsening shortness of breath beyond your baseline; however, you were treated with steroids and bronchodilators with improvement. Based on only requiring short-term breathing treatments and a consultation for your minor eye injury, it was not expected that you would require hospital services that would likely cross
2 midnights. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 22, 2021, through
June 23, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on February 17, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that you fainted, and someone called the paramedics on your behalf. You also say that you refused transport because you were advised that all of the hospitals in the area had a five hour wait time to get into the emergency room
due to the Coronavirus. The Plan denied your request. The Plan says you refused to be transported by ambulance. The Plan also says that this service is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport. The ambulance company did not provide transport services on February 17, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. The documentation submitted did not include a trip report or clinical information to verify if transportation was rendered. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on February 17, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the chiropractic services and the office visit to be
provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the chiropractic services and the office visit. You say that you feel safe and
satisfied with this provider's services and would like to continue seeing him. 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 chiropractic services and the office visit
to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy with an out-of-network provider.

You asked the Plan to pre-approve out-of-network physical therapy. You say that he suffered an acute rupture of the Achilles tendon and has elected non-operative treatment. You say that he is currently residing in another state and needs therapy while staying there. The Plan denied your request. The Plan says in-network providers are available, and the enrollee can follow up with the Plan regarding moving out of state.

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 physical therapy with an out-of-network provider.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay the in network rate for the inpatient hospital services provided from May 3, 2020, to May 5, 2020.

You asked the Plan to pay the in network rate for the inpatient hospital services. You say that You say that you were taken to the emergency room with a bad infection. You say that it was determined you needed to be admitted for surgery as soon as possible. You say that there were no rooms in the entire system in your area. You say that you were transferred to a different hospital since the care you needed could not be provided due to the coronavirus restrictions. You also say that the services should be covered at the in network rate since there were no in network hospitals available to provide the services. The Plan denied your request. The Plan says that the out of network cost share was 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 says that if you are using an out-of-network provider for emergency care, urgently needed services, or out-of-area dialysis, you may not have to pay a higher cost-sharing amount. 

We looked at your request, the file and rules. Based on this information we determined that the rules for coverage at the in-network level have been met. Specifically, you indicate that you were referred to the out-of-network facility by the Plan because there were no in-network providers available who could safely render this service. We requested additional information from the Plan to verify this information and none was received. The Plan does not address your appeal argument in their letter so we must find in your favor. Therefore, we decided that the Plan has to pay the in network rate for the inpatient hospital services provided from May 3, 2020, to May 5, 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: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the interim partial denture. 
 
You asked the Plan to pre-approve the interim partial denture. The Plan denied your request. The Plan says the 
service 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 pre-approve the 
interim partial denture
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the wheelchair accessories rendered on February 26, 2021.
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 provider is not Medicare-certified.
The Plan must follow Medicare rules. The rules say that Medicare pays for services only when they are furnished by a provider or supplier enrolled in the Medicare program. We looked at the file and Medicare rules. The file shows that the provider was not Medicare certified for the date of service at issue. Therefore, we decided that the Plan does not have to pay for the wheelchair accessories rendered on February 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia and supplies rendered on January 12, 2021.
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 a status indicator of I represents a code that is not valid
for Medicare purposes. 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 99199 (unlisted special service, procedure or
report) is not valid to bill as an anesthesia code. Codes S1015 (IV tubing set) and S8301 (infection control
supplies) have a status indicator of I and are not valid for Medicare purposes. Therefore, we decided that the
Plan does not have to pay for the anesthesia and supplies rendered on January 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve aspiration and/or injection of large joint or joint capsule (CPT code 20610).
You asked the Plan to pre-approve this service. You say that you are afraid you could fall and hurt yourself. The Plan denied your request. The Plan says you have right hip osteoarthritis and your provider has requested injection of a viscosupplement into your right hip joint. You state the record sent by your provider indicates you have right hip osteoarthritis and a prior hip injection in 2019 provided 50% relief however the medication injected is not documented.
The Plan must follow Medicare rules. 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. The rules say viscosupplementation of joints other than the knee(s) are considered not reasonable and necessary and are not subject to coverage. Therefore, we decided that the Plan does not have to pre-approve aspiration and/or injection of large joint or joint capsule (CPT code 20610).
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on February 15, 2021.
You asked the Plan to pay for the ambulance response and treatment with no transport. You say that the enrollee did not want to be transported to the hospital due to Coronavirus concerns. The Plan denied your request. The Plan says this service is not covered by Medicare.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.
The ambulance company did not provide transport services on February 15, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment with no transport (A0998) provided on February 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 1, 2021, to April 2, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says the services could have been provided at a lower level of care. The Plan also says that the services were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. 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 acute inpatient hospital care. Our reviewer
says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the provided documentation indicates that you were found to be in atrial fibrillation during a procedure. The reviewer found that you were admitted for cardiology consultation who found you hemodynamically stable and was essentially asymptomatic. The reviewer found that there was no cardioversion recommended and outpatient follow-up was recommended. The reviewer found that based on the low severity of the initial clinical course and no planned inpatient procedure or treatment being required for his atrial fibrillation, it was not expected that you would require hospital services that would likely cross 2 midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Specifically, the file shows the services could have been provided at a lower level of care. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from April 1, 2021, to April 2, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided on October 27, 2020.

You asked the Plan to pay for the laboratory services. The Plan denied your request. The Plan says Original Medicare is responsible 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 laboratory services provided on October 27, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient psychiatric care from August 9, 2021, forward.
You asked the Plan to pay for inpatient psychiatric care. You say that the services at issue were medically necessary. The Plan denied your request. The Plan says the services at issue were not medically necessary.
The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.
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 psychiatric care. Our reviewer says that the enrollee does not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of August 9, 2021, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond August 9, 2021, as she was not a danger to herself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis. 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 psychiatric care have not been met. Therefore, we decided that the Plan does not have to pay for inpatient psychiatric care from August 9, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuous glucose monitor.

You asked the Plan to pre-approve the requested device. You say that you are not going to mutilate your skin again. The Plan denied your request. The Plan says the criteria for coverage has not been met.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation does not indicate that you use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of the requested device have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor.