Persius/hicric huggingface dataset:
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on January 22, 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. Medicare rules say that claims submitted where the unit of service exceeds the MUE value for the HCPCS/CPT code will be denied. In this case, the MUE for CPT code 86077-59 is 1. You billed 2 units of this code, exceeding the MUE. 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 laboratory services rendered on January 22, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for continuation of an inpatient stay provided from December 14, 2020,
through December 15, 2020.

You asked the Plan to pay for continuation of the inpatient stay. You say that the inpatient stay was medically
necessary. The Plan denied your request. The Plan says that the inpatient stay from December 14, 2020,
through December 15, 2020, was not medically necessary. Based on the records, the care could have been
delivered in an alternate level of care such as home with home health care.

The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item
or service, then that item or service will be covered when it is 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 pay for the inpatient stay. Our reviewer says that the
inpatient stay is considered medically reasonable and necessary in this case. Our physician reviewer found that
the enrollee was admitted with congestive heart failure and acute kidney injury. The record indicates that on
December 14, 2020, the enrollee still had melanotic stools and required that Eliquis be restarted. The enrollee
was still being in diuresis however the creatinine was trending up. The record submitted supports the medical
necessity and reasonableness of the requested service as defined by Medicare rules. The elements of the
coverage criteria are satisfied. The requested service is recommended.

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 stay have been met. Therefore, we decided that the Plan has to pay
for continuation of an inpatient stay provided from December 14, 2020, through December 15, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay forthe laboratory services provided on February 15, 2021, by an out of network (OON) provider.You asked the Plan to pay forthe laboratory services. You say that you would like this claim reprocessed and approved for payment.The Plan denied your request. The Plan says prior authorization was not obtained for services rendered by an OON provider. 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 forthe laboratory services provided on February 15, 2021, by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an oral appliance for obstructive sleep apnea (OSA) treatment (E0486) for the enrollee.
You asked the Plan to pre-approve an oral appliance. You say that the enrollee is unable to tolerate a CPAP (continuous positive airway pressure) machine. The Plan denied your request. The Plan says that it would seem to be a premature appeal for an oral appliance when it is not demonstrated that the member has failed her newly approved CPAP machine.
The Plan follows Medicare rules. Medicare rules say that an oral appliance for OSA treatment when LCD criteria is met. 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 an oral appliance. Our reviewer says that an oral appliance for obstructive sleep apnea treatment is not medically reasonable and necessary for the enrollee. The patient with sleep apnea reported that CPAP aggravates her temporomandibular joint. A new and approved CPAP machine was requested and not used yet and is designed to alleviate any associated jaw pain. An oral appliance for OSA treatment was separately requested. Based on the fact that the patient has not yet tried and failed the new and improved CPAP machine, a new request for a different device would be premature. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for an oral appliance for obstructive sleep apnea treatment. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an oral appliance have not been met. Therefore, we decided that the Plan does not have to pre-approve an oral appliance for obstructive sleep apnea (OSA) treatment (E0486) for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for Vitamin D; 25 hydroxy, includes fraction(s), if performed
(CPT code 82306) provided to the enrollee on November 4, 2020.

You asked the Plan to pay for the laboratory services. You say that the claim should be paid. The Plan denied
your request. The Plan says the service is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few
tests listed above, are not covered.

Medicare does not cover this test solely for screening purposes. Medicare says preventative vitamin assays and
metabolic function tests are not a covered benefit (exception: chronic kidney disease stage III). Medicare
considers vitamin assay panels (more than one vitamin assay) a screening procedure and therefore, non covered.
Similarly, assays for micronutrient testing for nutritional deficiencies that include multiple tests for
vitamins, minerals, antioxidants and various metabolic functions are never necessary. Any diagnostic
evaluation should be targeted at the specific vitamin deficiency, and not a general screen. Most vitamin
deficiencies are nutritional in origin and may be corrected with supplemented vitamins. Therefore, we decided
that the Plan does not have to pay for Vitamin D; 25 hydroxy, includes fraction(s), if performed (CPT code
82306) provided to the enrollee on November 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 23, 2021.

You asked the Plan to pay for the limited evaluation. You say that this service was necessary and not routine. The Plan denied your request. The Plan says you had a previous limited evaluation in January 2021, which was paid for by the Plan. Only one limited oral evaluation can be covered per plan year.

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 limited evaluation is requested in a frequency that is not covered under this benefit. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on March 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a walking boot (L4361) provided on September 22, 2020, by
an OON provider.
You asked the Plan to pay for a walking boot. You say that you did not know you needed prior authorization.
The Plan denied your request. The Plan says that these services are not urgent or emergent, nor were they
approved in advance.
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 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 a walking boot (L4361) provided on September
22, 2020, by an OON provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided on May 23, 2020.

You asked the Plan to pay for the physical therapy services. You say that medical records were provided.The Plan denied your request. The Plan says the documentation submitted on appeal consists of duplicates of medical documents previously reviewed.

The Plan must follow Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  

We looked at the file and Medicare rules.The file shows that you did not submit sufficient medical documents to justify payment of the claim. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met.Therefore, we decided that the Plan does not have to pay for physical therapy services provided on May 23, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay forthe supply allowance for a CGM (K0553) provided on February 14, 2021.You asked the Plan to pay forthe supply allowance for a CGM. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says multiple attempts have been made to obtain the explanation of benefits from thThe Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.The Plan has met its obligation with regards to coordination of benefits. Specifically, the Plan has directed the provider to send the bill to the primary insurer.. As the secondary insurer, the Plan cannot be held responsible for the supply allowance for a CGM until the primary insurer has denied the claim for these services.Therefore, we decided that the Plan does not have to pay forthe supply allowance for a CGM (K0553) provided on February 14, 2021.e member's primary insurance.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical service provided on October 21, 2020 billed with code 14040.

You asked the Plan to pay for the services as billed. You say that the services are billed correctly and should be paid. The Plan denied your request. The Plan says the code 14040 remains not supported by the records.

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 14040 is adjacent tissue transfer or rearrangement, of the forehead, cheeks, chin, mouth, neck, axillae, genitalia,hands and/or feet; defect 10 sq cm or less.

We asked our coding 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 services as billed. Our reviewer says that
the billed code is not supported by the records. Our coding reviewer found the operative report does not support an adjacent tissue transfer. An adjacent tissue transfer over skin or tissue graft is the part of the flap that remains connected to its origin. This way, the flap has an intact and continuous blood supply. This means that the tissue will not lose blood supply even while waiting for new blood vessels to grow on the recipient site. A skin graft is a piece of tissue that is separated completely from its origin. Thus, it has to wait for new blood vessels to grow before it can receive a supply of blood again. The operative report documents donor site is "left preauricular cheek", and recipient site is on "left nasal sidewall". Therefore, this is the incorrect code to report for this 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 as billed have not been met. Therefore, we decided that the Plan does not have to pay for the surgical service provided on October 21, 2020 billed with code 14040.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the out-of-network referral for a Quadriceps-Sparing total knee replacement.

You asked the Plan to pre-approve the out-of-network referral for a Quadriceps-Sparing total knee replacement. You say that you would like reconsideration because this is the best procedure considering your age. The Plan denied your request. The Plan says the requested Quadriceps-Sparing total knee replacement is not medically necessary and the standard of care is available within the Plan's network.

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 out-of-network referral for a Quadriceps-Sparing total knee replacement. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the minimally invasive approach of quadriceps sparing total knee arthroplasty, has limited published, large-scale, long-term peer-reviewed literature that shows the request to be an effective and/or safe treatment for the noted pathology. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception.

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 out-of-network referral for a Quadriceps-Sparing total knee replacement have not been met. Therefore, we decided that the Plan does not have to pre-approve the out-of-network referral for a Quadriceps-Sparing total knee replacement.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments forfacet joint injections provided from November 24, 2020, to December 29, 2020.You asked the Plan to waive the copayments forfacet joint injections. You say that you were not aware that you would owe such a high copayment and feel that you should only owe specialist copayments.The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $395 copayment for outpatient surgery and other medical services proThe record shows that you received facet joint injections at an outpatient hospital facility from November 24, 2020, to December 29, 2020, for a total of 3 injections. Facet joint injections are considered outpatient surgical procedures. Therefore, you are responsible to pay a $395 copayment per each injection. The total amount you owe is: $395 (copayment) x 3 (facet joint injections) = $1,185. You have been asked to pay the total copayment amount of $1,185 for facet joint injections. Facet joint injections fall within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments forfacet joint injections provided from November 24, 2020, to December 29, 2020.vided at hospitaloutpatient facilities and ambulatory surgical centers.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit with a cardiologist (99214) provided on January 4, 2021, by an out of network (OON) provider.
You asked the Plan to pay for an office visit. You say that you were not given proper information when you joined the plan. You also say that you were not aware your provider was not in network. The Plan denied your request. The Plan says services were provided by an out-of-network provider without prior authorization.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan 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. The records provided for review do not show that the services at issue were urgent or emergent. 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 an office visit with a cardiologist (99214) provided on January 4, 2021, by an out of network (OON) provider.
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 these services are medically necessary. The Plan denied your request. The Plan says that the enrollee's needed care can be safely given in a lower level of 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 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 left sided paralysis after a fall. He had cervical spine fusion. He was discharged to a skilled nursing facility on June 4, 2021. The
enrollee's medical conditions 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. The patient 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the requested IRF care is a medical necessity for you. The Plan denied your request. The Plan says rules for IRF care have 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 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 that the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. You do require physical and occupational therapy but there is no documented need for an intensive 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. 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 IRF admission and services.