Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that a LTACH admission is medically necessary. The Plan denied your request. The Plan says under Medicare, the request is not medically necessary.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found that there is no documentation provided indicating medical necessity for admission to a LTACH. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care. The are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit and supplies (99072 and 99203) provided on January 2, 2021.
You asked the Plan to pay for the office visit and supplies. You say that you would like reconsideration because you believe this service should be covered by the Plan. The Plan denied your request. The Plan says this claim was billed with an inappropriate diagnosis code for the services rendered.
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 codes 99072 and 99203 are not supported in the medical record. Specifically, the provider has indicated that this was a walk-in/drive-up clinic for COVID testing.
Per Medicare, this service must be billed with a different CPT code. The documentation submitted does not support the billing of CPT codes 99072 and 99203. Based on this information, we decided that Medicare rules for coverage of the office visit and supplies have not been met. Therefore, we decided that the Plan does not have to pay for the office visit and supplies (99072 and 99203) provided on January 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services (99199) provided November 3, 2020.
You asked the Plan to pay for the anesthesia services. You say that these services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 99199 is Unlisted special service, procedure or report. We find that CPT code 99199 is not supported in the medical record. Specifically, the provider is reporting CPT 99199 separately for Post-anesthesia Care. Per Medicare guidelines, Anesthesia care consists of preoperative evaluation, standard preparation and monitoring services, administration of anesthesia and post-anesthesia recovery care. Therefore, this service should not be reported separately.
Based on this information, we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99199) provided November 3, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided to the enrollee from August 10, 2020, to August 28, 2020, and billed with a PDPM of KAKE1.
You asked the Plan to pay for the services. You say that this was billed correctly. The Plan denied your request. The Plan says the documentation does not support a diagnosis of respiratory failure and these services should be billed with a PDPM of LAQF1.
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 found the physician documentation does not support an active diagnosis of respiratory failure between the dates of August 10, 2020, through August 28, 2020.
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 skilled nursing facility (SNF) care provided to the enrollee from August 10, 2020, to August 28, 2020, and billed with a PDPM of KAKE1.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care provided December 26, 2019 to December 30, 2019.
You asked the Plan to pay for inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says that DRG 194 is more appropriate for the services billed.
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 DRG 871. 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 reviewer says that the documentation supports the DRG billed. Our physician reviewer found the records support sepsis due to pneumonia and complicated by rhabdomyolysis. DRG 871 is supported by the records. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for inpatient hospital care provided December 26, 2019 to December 30, 2019.
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 for injections (J3411, J3415, J3490, J1955, & 97139) provided November 17, 2020.
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT code J3411, J3415, J3490, J1955, & 97139 is not supported in the medical record. Specifically, the procedure report documents "Nurtri-pharmaceutical injections were administered". Provider billed J3411, J3415, J3490 and J1955 separately, which resulted in incorrect billing, and therefore, would not be reimbursed separately. Documentation does not support the reporting of CPT 97139.
When reporting an unlisted code, documentation should include description of the unlisted code, therefore, this procedure cannot be confirmed. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (J3411, J3415, J3490, J1955, & 97139) provided November 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for post-anesthesia care unit (PACU) nurse services (99199) provided on February 19, 2021.
You asked the Plan to pay for PACU nurse services. You say that the services were provided, and payment should be rendered. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 99199 is PACU nurse services. 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 PACU nurse services. Our reviewer says that the documentation does not support the separate billing.
Our reviewer found per CMS guidelines for anesthesia care package consists of preoperative evaluation, standard preparation and monitoring services, administration of anesthesia, and post-anesthesia recovery care. Therefore, this procedure should not be separately reported. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PACU nurse services have not been met. Therefore, we decided that the Plan does not have to pay for post-anesthesia care unit (PACU) nurse services (99199) provided on February 19, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the CGM supply allowance (K0553 and K0554) provided on March 8, 2021.
You asked the Plan to pay for the CGM supply allowance. You say that you would like reconsideration because the requested supplies are medically necessary. The Plan denied your request.
The Plan says the documentation does not support that the requested supplies are medically necessary or that the physician discussed the need for the requested supplies.
The Plan follows Medicare rules. The rules say that therapeutic CGMs may be considered reasonable and necessary for enrollees with diabetes who meet the criteria referenced 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 pay for the CGM supply allowance. Our reviewer says that Medicare coverage criteria have not been met. Our physician reviewer found the record does not show that the member requires frequent adjustments in insulin doses due to their blood glucose level. 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 CGM supply allowance have not been met. Therefore, we decided that the Plan does not have to pay for the CGM supply allowance (K0553 and K0554) provided on March 8, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for needle electromyography (95885) and nerve conduction studies (95908) provided on December 21, 2020.
You asked the Plan to pay for the needle electromyography and nerve conduction studies. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the services billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code 95885 is needle electromyography, each extremity, with related paraspinal areas, when performed, done with nerve conduction, amplitude and latency/velocity study; limited (List separately in addition to code for primary procedure).
The CPT code Manual definition of code 95908 is nerve conduction studies; 3-4 studies. 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 needle electromyography and nerve conduction studies. Our reviewer says that CPT code 95885 does not meet criteria for billing or reimbursement consideration. The medical records provided do not document that a limited needle electromyography with nerve conduction was performed on December 21, 2020. The medical records document that pedicle screw stimulations were performed which are not baseline nerve conduction studies, therefore this service cannot be verified. Our reviewer found CPT code 95908 does not meet criteria for billing or reimbursement consideration. The medical records provided do not document that a nerve conduction study of 3-4 studies was performed. The medical records document that pedicle screw stimulation was performed which are not baseline nerve conduction studies and do not meet the definition of CPT code 95908. 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 needle electromyography and nerve conduction studies have not been met. Therefore, we decided that the Plan does not have to pay for needle electromyography (95885) and nerve conduction studies (95908) provided on December 21, 2020.
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from September 1, 2021, forward.

You asked the Plan to pre-approve inpatient psychiatric care from September 1, 2021, forward.. You say that inpatient psychiatric care from September 1, 2021, forward, is medically necessary. The Plan denied your request. The Plan says inpatient psychiatric care from September 1, 2021, forward, is 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 pre-approve inpatient psychiatric care from September 1, 2021, forward. Our reviewer says that you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of September 1, 2021 forward. Our physician reviewer found you did not require inpatient mental health treatment beyond September 1, 2021, as you were not a danger to yourself 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 your 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 from September 1, 2021, forward. have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from September 1, 2021, forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power scooter (K0800).

You asked the Plan to pre-approve the power scooter. You say that the power wheelchair is medically necessary. The Plan denied your request. The Plan says coverage criteria has not been met.

The Plan must follow Medicare rules. Medicare rules say that that payment may not be made for a motorized or power wheelchair unless the treating practitioner conducts a face-to-face encounter and writes a standard written order for the motorized or power wheelchair. 

We looked at the file and Medicare rules. There is no record of a face-to-face encounter or standard written order from the enrollee's treating physician. Based on this information, we decided that Medicare rules for coverage of the power scooter have not been met. Therefore, we decided that the Plan does not have to pre-approve a power scooter (K0800).
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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF 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 does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. 

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: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the infectious agent detection by nucleic acid (U0003) provided on August 4, 2020.

You asked the Plan to pay for the infectious agent detection. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the enrollee's terminal condition.

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 the infectious agent detection by nucleic acid (U0003) provided on August 4, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the immediate lower partial denture (D5224) provided on February 18, 2021.

You asked the Plan to pay for the dental service. You say that you plan covers lower partial dentures so the plan should cover an immediate lower partial denture too. You also say that you need this bill taken care of as soon as possible. The Plan denied your request. The Plan says the immediate lower partial denture is not listed as a covered service.

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 the immediate lower partial denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the immediate lower partial denture (D5224) provided on February 18, 2021.