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

We decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.

You asked the Plan to pre-approve inpatient hospital services. You say that the enrollee is severely anemic with recent left above knee amputation with a wound. The Plan denied your request. The Plan says that criteria for inpatient admission are not met.

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 pre-approve inpatient hospital services. Our reviewer says that inpatient hospital services are not medically reasonable and necessary for the enrollee.

The enrollee presented to the emergency department (ED) for low hemoglobin status post above knee amputation with wound dehiscence status post revision. The enrollee hemoglobin was 6.9 at the skilled nursing facility and the same repeated in ED. The right lower extremity was colder and difficult to palpate pulse. Doppler showed occlusion of right proximal superficial femoral artery but negative for deep vein thrombosis. He underwent peripheral angiogram but no interventions performed. The enrollee was hemodynamically stable without objective signs of active bleeding or need for a procedure. Based on the documented presentation, the patient did not appear to require hospital care that would likely cross 2 midnights. Our physician reviewer found that the enrollee's condition does not meet criteria for inpatient hospital services. 

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 hospital services have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient hospital services for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on November 11, 2020.
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 testing is not covered.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. The test at issue in this appeal, these services, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on November 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection SI joint (CPT code 27096 X2), for the enrollee.
You asked the Plan to pre-approve the injections. You say that the injections are necessary. The Plan denied your request. The Plan says the enrollee has their second therapeutic SI joint injection with 60% pain relief that lasted for a longer period. The Plan states a third SI joint injection has been requested and it has only been two (2) weeks since their last injection. The Plan state repeat therapeutic sacroiliac joint injections must be at least two (2) months from the previous injection.
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 injections. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is over-utilization of the procedure and the degree and duration of pain relief achieved is marginal. The request is not medically reasonable or 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 injections have not been met. Therefore, we decided that the Plan does not have to pre-approve injection SI joint (CPT code 27096 X2), for the enrollee.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pre-approve polysomnography (PSG) services.
You asked the Plan to pre-approve the PSG services. You say that the enrollee has a severe case of chronic obstructive pulmonary disease. You say that the enrollee continues to have episodes alone in her home. The Plan denied your request. The Plan says the clinical information provided does not have documentation of the enrollee's neck circumference.
The Plan follows Medicare rules. Medicare rules say that sleep testing is covered for certain medical indications. 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 PSG services.
Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found an attended PSG is considered not medically necessary. The enrollee underwent a PSG in 2009, which did not meet criteria for obstructive sleep apnea (OSA) but did show disturbed sleep from restless leg syndrome. The recent clinical note from May 26, 2021, does not provide a complete sleep history, and only shows the Epworth score of 2, indicating no excessive daytime sleepiness. Insomnia is listed as a diagnosis with no supporting information in the history. The enrollee is not obese. There is no mention of snoring or observed apneas. With this information, the suspicion for OSA is very low, and an attended PSG is not clinically indicated. 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 PSG services have not been met. Therefore, we decided that the Plan does not have to pre-approve polysomnography (PSG) services.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from January 5, 2021, through February 3, 2021.

You asked the Plan to pay for the SNF services. You say that it is felt Medicare payment should be made for these dates. The Plan denied your request. The Plan says the care provided during this date span was custodial and not covered by Medicare.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found at the time of admission to the SNF, the member required skilled rehab services to improve function due to weakness and deconditioning. There were no skilled nursing needs. As of 1/5/2021 the member did not require any skilled nursing or rehab services on a daily basis. She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or daily living activities. The member did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the member did not require any skilled services on an inpatient basis, at a SNF level of care as of 1/5/2021. 

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 SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from January 5, 2021, through February 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from February 6, 2021, through February 22, 2021.
You asked the Plan to pay for the SNF services. You say that it is felt that Medicare payment should be made for these dates. The Plan denied your request. The Plan says the services provided during this time frame were custodial in nature.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 pay for the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have documented skilled nursing needs. The enrollee did not have documented skilled therapy needs. Daily skilled services were not required to establish a maintenance program or to prevent deterioration of the enrollee's condition. The enrollee's care needs at this point were custodial and, as a practical matter, could be provided at a lower level of 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 the SNF services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided from February 6, 2021, through February 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for orthoses (L0650, L3670) provided December 23, 2020.
You asked the Plan to pay for the orthoses. You say that the items were medically necessary. The Plan denied
your request. The Plan says the documentation does not support the billed services.
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a
physician order and proof of delivery.
The record does not contain valid medical records which support medical necessity for the supplies provided in
this case. The record shows no history of an evaluation and management service provided by the ordering physician. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for orthoses (L0650, L3670) provided December 23, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (G0483) provided February 18, 2020.
You asked the Plan to pay for the lab services. 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 G0483 is not supported in the medical record. Specifically, the place of service on the claim (81, laboratory) does not match the place of service detailed in the records (11, office setting). Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (G0483) provided February 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (14302) provided November 23, 2020.
You asked the Plan to pay for the surgical services. 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. In this case, the CPT Code Manual definition of code 14302 is adjacent tissue transfer or rearrangement of any area for each additional 30.0sq cm. We find that CPT code 14302 is not supported in the medical record. Specifically, the record did not show a tissue transfer of an additional 30.0sq cm. Based on this information, we decided that Medicare rules for
coverage of the surgical services have not been met. Therefore, we decided that the Plan does not have to pay for surgical services (14302) provided November 23, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug/vitamin provided in the nutria-pharmaceutical injection on December 10, 2020, billed with code J3490-KQ.
You asked the Plan to pay for the billed drug. You say that this was billed correctly and should be paid. The Plan denied your request. The Plan says this is not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that compounded drugs must be reported using the NOC compounded drug code. In this case, multiple agents are compounded into a single pre-filled syringe. This should be reported as J7999, compounded drug NOC. Therefore, we decided that the Plan does not have to pay for the drug/vitamin provided in the nutria-pharmaceutical injection on December 10, 2020, billed with code J3490-KQ.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF care.
You asked the Plan to pre-approve SNF care. You say that you are weak, you had six (6) strokes, are on a feeding tube and need therapy to be able to get back to yourself but are not being given therapy in the hospital. The Plan denied your request. The Plan says the stay is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section 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 SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you have stabilized medically and are ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehab services at a lower level of care. Although further rehab services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a SNF. You do not have any parental medication; or complex wound care. You are medically stable without any acute exacerbation of chronic medical problems. Your physical function is at or near their baseline and you can receive services at a lower level of care. You continue to require total custodial care. Admission to a SNF for inpatient skilled rehab services 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the computed tomography, head or brain; without contrast material (70450) provided on July 24, 2020.
You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to the service provided.
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 $0 copayment for mammography and ultrasounds and a $195 copayment for all other diagnostic and nuclear medicine radiological services. You have been asked to pay $130.83 for the diagnostic radiological service provided. This is the Plan's allowed amount for this service, which is less than the applicable copayment. 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 computed tomography, head or brain; without contrast material (70450) provided on July 24, 2020.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for the needle electromyography, each
extremity (95886) and the nerve conduction studies (95912, 95913) provided on February 1, 2021 and
March 22, 2021.
You asked the Plan to waive the copayments. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayments have been applied correctly to
the services provided.
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 $0
copayment for EKG (electrocardiogram) and diagnostic colorectal screenings and a $150 copayment for all
other diagnostic procedures and tests.
You have been asked to pay $300 ($150 copayment x 2) for the diagnostic tests provided. 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 for the needle electromyography, each extremity (95886) and the nerve
conduction studies (95912, 95913) provided on February 1, 2021 and March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for outpatient services (G0463) provided on February 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the outpatient services. You say that the services were medically necessary. The Plan denied your request. The Plan says the services were not emergent or pre-authorized.
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 services at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for outpatient services (G0463) provided on February 26, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for laboratory services provided to the enrollee on January 12, 2021.
You asked the Plan to pay for laboratory services provided on January 12, 2021. You say that this claim should be paid. The Plan denied your request. The Plan says that Medicare denies coverage for all cardiovascular risk assessment panels, except the basic lipid panel, for patients with suspected or documented cardiovascular disease. You can find this Medicare guidance in the Medicare Local Coverage Article: Billing and Coding: MolDX: Biomarkers in Cardiovascular Risk Assessment (A57559), and the Local Coverage Determination (LCD): MolDX: Biomarkers in Cardiovascular Risk Assessment (L36523).
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Medicare regulations referenced by the Plan are not within the MAC B coverage jurisdiction for either the Plan or the enrollee. Therefore, the criteria they based their decision on the not apply. The Plan has not substantiated its denial. Therefore, we decided that the Plan has to pay for laboratory services provided to the enrollee on January 12, 2021.
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 the critical care services rendered from January 22, 2021 to January 25, 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 procedure code 99291 is not supported.

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 99291 is Critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes. 

We find that CPT code 99291 is not supported in the medical record. Specifically, there is no documentation of the first 30-74 minutes of critical care spent on the enrollee for the dates of service at issue. 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 critical care services rendered from January 22, 2021 to January 25, 2021.