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

We decided that the Plan has to pay forobservation care (99217) provided September 24, 2019.You asked the Plan to pay forthe observation care. You say that the services were medically necessary.The Plan denied your request. The Plan says that the records do 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 CPTCode Manual definition of code 99217 is Hospital Observation Discharge Care.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 observation care. Our reviewer says that the records support the services billed. Our physician reviewer found the services were medically necessary and the documentation supports the billing of CPT 99217.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 observation care have been met.Therefore, we decided that the Plan has to pay forobservation care (99217) provided September 24, 2019.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay forthe home health services provided to the enrollee from October 2, 2019 to November 30, 2019.You asked the Plan to pay forhome health services. You say that you would like reconsideration based on the records submitted.The Plan denied your request. The Plan says the claim was not billed correctly per Medicare guidelines. The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the submitted claim does not include the required FIPS code.Therefore, we decided that the Plan does not have to pay forthe home health services provided to the enrollee from October 2, 2019 to November 30, 2019.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on January 7, 2020.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. We find that CPT codes 80307 and G0482 are not supported in the medical record. Specifically, the documentation submitted did not include a physician order/lab requisition or medical records stating exactly what tests were to be performed. Based on this information, we decided that Medicare rules for coverage of the drug testing have not been met. Therefore, we decided that the Plan does not have to pay for the drug testing coded 80307 and G0482 provided on January 7, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the arthroplasty services coded 27447 provided on December 20, 2019.
You asked the Plan to pay for the arthroplasty services. You say that you would like the plan to reconsider their denial The Plan denied your request. The Plan says the services were billed incorrectly.
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 27447 is arthroplasty, knee, condyle and plateau; medial AND lateral compartments with or without patella resurfacing (total knee arthroplasty). We find that CPT code 27447 is not supported in the medical record. Specifically, this service was billed without a required anatomical modifier. Based on this information, we decided that Medicare rules for coverage of the arthroplasty services have not been met. Therefore, we decided that the Plan does not have to pay for the arthroplasty services coded 27447 provided on December 20, 2019.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient stay provided from December
9, 2019 through December 14, 2019.
You asked the Plan to waive the copayment for the inpatient stay. You say that you were previously informed
that if you were admitted you wouldn't be responsible for any testing or procedures. You say that you had no
reason to believe that this stay was different than your previous stay. 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 $331 per
day, days 1-5 and $0 per day, days 6-90 for each medically necessary covered inpatient stay.
You have been asked to pay $1,653.66, which is less than the standard $1,655 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 December 9, 2019 through December 14, 2019.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for an outpatient visit (99214) provided on August 7, 2019.
You asked the Plan to pay for the outpatient visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that payment for this service is included in the global surgery package of another service.
The Plan must follow Medicare rules. Medicare rules say that visits unrelated to the diagnosis for which the surgical procedure is performed, unless the visits occur due to complications of the surgery are not included as part of the Global payment. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the outpatient visit. have been met. The record does not indicate that the outpatient visit provided on August 7, 2019 was related to the closed treatment of metatarsal fracture. Therefore, we decided that the Plan has to pay for an outpatient visit (99214) provided on August 7, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the special pump services rendered on April 30, 2019.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 separately payable.The Plan must follow Medicare rules. The rules say that procedure codes with a status indicator of X are statutorily excluded. The provider submitted a claim for procedure code 99190 (special pump services). This code has a status indicator of X and no separate Medicare payment. Payment is included in the payment to the facility.Therefore, we decided that the Plan does not have to pay for the special pump services rendered on April 30, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prolia 60mg/ml syringe for the enrollee. 
 
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee does not meet the step therapy criteria. 
 
Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 
 
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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found on the Prior Authorization Request Form completed on 1/15/20, Q21 (Has the patient had new fracture or significant loss of bone mineral density despite previous treatment, contraindication, or intolerance with zoledronic acid?) is checked Yes. However, there are no clinical records in the case file supporting that the enrollee has tried and failed the required drug.  The documentation is insufficient to support that zoledronic acid would likely be less effective, and/or would likely have adverse effects for the enrollee in this case. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Prolia 60mg/ml syringe for the enrollee.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Supartz FX injection for the enrollee.
You asked the Plan to pre-approve the injection. You say that this is medically necessary. The Plan denied your request. The Plan says step therapy guidelines were not followed.
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 the injection. Our reviewer says that the requested injection is not medically reasonable or necessary. Our physician reviewer found the enrollee has not trialed viscosupplemental treatments such as Orthovisc and Monovisc. Step therapy, as outlined by the plan, requires these be trialed first. The documentation does outline contraindications or reasons these medications were not considered. Without the support of the documentation, Supartz FX is not approved as step criteria is not met. 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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve Supartz FX injection for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the continuation of SNF care. You say that the enrollee needs regular therapy to get stronger and to continue movement on her own. You say that if the enrollee does not continue therapies, she may end up wheelchair bound. You say that this would be detrimental to the enrollee's physical abilities, result in extra care required at the nursing facility, and potentially put the health plan in a position where they would have to pay for other medical services that could have been prevented with the requested rehab. The Plan denied your request. The Plan says the enrollee does not meet the criteria for coverage of the requested SNF care.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed above are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the continuation of SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee is needing assist for all care. The enrollee has no complex wound care needs, or IV medication requirements. There are no nursing or therapy needs that are skilled, and warranting a SNF as opposed to a lesser level of care. The enrollee's vital signs are stable. SNF care 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 the continuation of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuation of skilled nursing facility (SNF) services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for facet joint injections (64495) provided on October 22, 2019.
You asked the Plan to pay for the facet joint injections. 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 service 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 64495 is injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure). 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 facet joint injections. Our reviewer says that CPT code 64495 does not meet criteria for billing or reimbursement consideration. Our reviewer found the medical records provided do not include documentation of an injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (List separately in addition to code for primary procedure). The medical record documented that 3 medical branch blocks were performed. This results in only 2 facet joints being blocked, therefore this service cannot be verified.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
You asked the Plan to pre-approve the CT scan. You say that the requested CT scan is needed for surveillance of typical carcinoid. The Plan denied your request. The Plan says the clinical information provided does not meet the criteria for coverage or describe the allowed imaging time frame.
The Plan must follow Medicare rules. Medicare rules say that CT 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 CT scan. Our reviewer says that the requested CT Scan is not medically necessary. Our physician reviewer found surveillance for primary lung carcinoid tumors after more than one yeast post-resection is a CT every 12-2 months. The enrollee was treated in 2017 and last had imaging in October 2019. The enrollee would not be due for additional imaging unless there were signs or symptoms of recurrence. 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 CT scan have not been met. Therefore, we decided that the Plan does not have to pre-approve computed tomography (CT) scan services.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for office visits provided on July 31, 2019 through October 9, 2019.
You asked the Plan to pay for the office visits. You say that you would like reconsideration because you are at a critical point in your psychotherapy and need to continue seeing this provider. The Plan denied your request. The Plan says this provider is not contracted with Medicare to be reimbursed for services and is not eligible for payment.
The Plan must follow Medicare rules. Medicare rules say that Masters in Social Work are not eligible to enroll in Medicare. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the office visits have not been met. Specifically, the record indicates that this provider is a Master in Social Work. This provider type is not eligible to enroll in Medicare or receive payment. Therefore, we decided that the Plan does not have to pay for office visits provided on July 31, 2019 through October 9, 2019.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for SNF services provided on July 1, 2019 through July 11, 2019.You asked the Plan to pay for the SNF services. You say that the member was not discharged, but their number of Medicare days ended. The Plan denied your request. The Plan says that the claim was submitted and billed with 11 days but services were provided for 10 as the discharge day does not count.The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. We find that the SNF services are supported in the record. Specifically, the record indicates that the member was not discharged on the 11th day, but put under different coverage. Basedon this information, we decided that Medicare rules for coverage of the SNF services have been met. Therefore, we decided that the Plan has to pay for SNF services provided on July 1, 2019 through July 11, 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 an electrocardiogram (93010) and intubation (31500) provided on November 24, 2018.
You asked the Plan to pay for the electrocardiogram and intubation. 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 93010 is electrocardiogram, routine ECG with at least 12 leads; interpretation and report only. The CPT Code Manual definition of code 31500 is intubation, endotracheal, emergency procedure. 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 electrocardiogram and intubation. Our reviewer says that CPT code 93010 does not meet criteria for billing or reimbursement consideration. there is no documentation to support that CPT code 93010 was rendered. Our reviewer found CPT code 31500 does not meet criteria for billing or reimbursement consideration. The documentation submitted does not support this code and another code would be more appropriate. 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 electrocardiogram and intubation have not been met. Therefore, we decided that the Plan does not have to pay for an electrocardiogram (93010) and intubation (31500) provided on November 24, 2018.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for ultrasounds (76604 and 76881) provided on October 8, 2019.
You asked the Plan to pay for the ultrasounds. 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 76604 is ultrasound, chest (includes mediastinum), real time with image documentation. The CPT Code Manual definition of 76881 is ultrasound, complete joint (ie, joint space and peri-articular soft-tissue structures), real-time with image documentation. 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 ultrasounds. Our reviewer says that CPT codes 76604 and 76881 do not meet criteria for billing or reimbursement consideration. Our physician reviewer found the documentation does not provide evidence that ultrasound imaging of the chest or an extremity joint was performed. 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 ultrasounds have not been met. Therefore, we decided that the Plan does not have to pay for ultrasounds (76604 and 76881) provided on October 8, 2019.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for outpatient surgery provided on August 8, 2019.
You asked the Plan to waive the copayment for outpatient surgery. You say that you do not know why you are being charged so much for a specialist visit. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.
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 $250 copayment per day for outpatient surgery at an outpatient hospital. The provider is considered to be an outpatient hospital facility, therefore the outpatient hospital surgery copayment applies to this claim. You have been asked to pay the allowed amount of $190.44, which is less than $250 copayment per day for outpatient surgery. Outpatient surgery falls within the Outpatient Surgery, Including 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 copayment for outpatient surgery provided on August 8, 2019.