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

We decided that the Plan does not have to pay for laboratory testing provided on January 14, 2021.
You asked the Plan to pay for lab tests. You say that the physician ordered this testing after making a
professional determination of medical necessity. The Plan denied your request. The Plan says the denial of
payment for this testing is correct, because professional interpretation of diagnostic testing must be separately
billed with modifier -26 by the interpreting physician.
The Plan must follow Medicare rules. Medicare rules say that payment is not made under the physician fee
schedule for technical component (TC) services furnished in institutional settings where the TC service is
bundled into the facility payment.
We looked at the file and Medicare rules. You billed these services globally; however, these tests were
performed on a hospital outpatient and therefore the TC service is bundled into the facility payment. Based on
this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we
decided that the Plan does not have to pay for laboratory testing provided on January 14, 2021
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 70 hours per week of a home health aide.

You asked the Plan to pre-approve the additional hours. You say that this is medically necessary. The Plan denied your request. The Plan says 37 hours a week is appropriate.

The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the additional hours. Our reviewer says that the requested additional hours are not medically reasonable or necessary. Our physician reviewer found there are no documented skilled nursing or skilled therapy needs. You do have multiple sclerosis, and likely need assistance with activities of daily living (ADLs) instrumental activities of daily living (IADLs). The documentation does not show why such care must be provided by a home health aide, or how such care is medically necessary to treat illness or injury. The care needs appear to be custodial. As such, the number of requested hours is not shown to be medically necessary or reasonable. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the additional hours have not been met. Therefore, we decided that the Plan does not have to pre-approve 70 hours per week of a home health aide.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services provided on September 10, 2020.
You asked the Plan to pay for the services provided. You say that you have no knowledge of patient coverage prior to the specimen's arrival at the laboratory. The Plan denied your request. The Plan says the billed services cannot be verified.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We looked at the file and the rules. The claim shows a place of service as an independent laboratory. The records do not indicate the specimen was obtained at an independent laboratory. The rules say that the place where the sample was taken is reported as the POS. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on September 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the stay is medically necessary. The Plan
denied your request. The Plan says continued management can be provided in the acute care hospital until the
enrollee's course of care is complete. The Plan states when the enrollee is ready to leave the hospital, the
enrollee will not need to see a doctor every day. The Plan states the wound VAC wound care the enrollee
requires does not require specialty nursing care and can be safely managed by skilled nursing care. The Plan
states as the enrollee recovers from their wound issues, they will need continued care, including skilled nursing
for the enrollee's intravenous (IV) antibiotics, wound care, and therapy. The enrollee can safely receive this
care in another setting, such as a skilled nursing facility (SNF) and the enrollee's doctor says the enrollee will
receive their IV antibiotics as an outpatient.
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 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 they are currently
receiving care. There 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 LTACH services.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, basic life support,
non-emergency transport (A0428) and ground mileage (A0425) provided May 19, 2021.
You asked the Plan to waive the copayment for the non-emergency ambulance transport. You say that you
cannot afford the copayment. The Plan denied your request. The Plan says the copayment has been 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 a $325
copayment per trip for Medicare-covered ambulance services.
You have been asked to pay a $283.88 copayment for the non-emergency ambulance transport. The nonemergency
ambulance transport falls within the Ambulance services benefit category. This means that you
have been asked to pay less than or equal to 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 ambulance service, basic life support, non-emergency
transport (A0428) and ground mileage (A0425) provided May 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation - established patient (D0120) provided June 24, 2021.
You asked the Plan to pay for the periodic oral exam. You say that this is the first time you have had this service in two years. The Plan denied your request. The Plan says this procedure is only covered once per 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. The Plan covers a periodic, limited, problem-focused, or comprehensive evaluations once per calendar year. We looked at the file and Medicare rules. The Plan provided documentation showing that a comprehensive oral exam was previously covered on March 30, 2021. Based on this information, we decided that the Plan's
frequency limit for coverage of the periodic oral exam has been exceeded. Therefore, we decided that the Plan
does not have to pay for the periodic oral evaluation - established patient (D0120) provided June 24, 2021
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 the stay is medically necessary. 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 do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. Daily skilled services are not shown to be required to establish a maintenance program or to prevent deterioration of your condition. Your care needs, as a practical matter, can 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 SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF care
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the office visit (CPT code 99213) to be provided by an out-of-network provider.

You asked the Plan to pre-approve the office visit. You say that the enrollee asked them to be referred for a second opinion with this provider. The Plan denied your request. The Plan says there are in-network providers that can render the services. Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers. The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the office visit (CPT code 99213) to be provided by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90834) provided on March 23, 2021.

You asked the Plan to pay for the psychotherapy services. You say that you would like this claim reprocessed based on the medical necessity of services. The Plan denied your request. The Plan says there was no documentation of consultation with the attending or primary care physician in the patient's medical record.

The Plan must follow Medicare rules. Medicare rules say that the CP must document, in the patient's medical record, the date the patient consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, that date and manner of notification to the physician. 

We looked at the file and Medicare rules. In this case, the provider has not documented in the medical record the date the enrollee consented or declined consent to consultations, the date of consultation, or, if attempts to consult did not succeed, the date and manner of notification to the physician. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90834) provided on March 23, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for the life vest provided on March 14, 2021.

You asked the Plan to waive the coinsurance for the life vest. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a life vest on the date of service at issue in this appeal. The Plan says that the correct coinsurance has applied per your contract with the Plan.

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 20% coinsurance for Durable medical equipment. 

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a life vest on March 14, 2021. You have been asked to pay a 20% coinsurance for the life vest, totaling $586.29. The life vest falls within the Durable medical equipment 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 coinsurance for the life vest provided on March 14, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the walk-in bathtub provided from November 12, 2020 to December 29, 2020.
You asked the Plan to pay for the walk-in bathtub. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is available to the general public and would be helpful even to those who are not sick or injured. Therefore, we decided that the Plan does not have to pay for the walk-in bathtub provided from November 12, 2020 to December 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management (99239) provided June 4, 2021.
You asked the Plan to pay for hospital discharge day management. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has processed correctly.
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, we have confirmed that code 99239 is a column II code to column I code 99223. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management (99239) provided June 4, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (95957, 95908, 95886, 95887) provided on October 7, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 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. 

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the use of codes 95957, 95908, 95886, and 95887, is not supported by the records provided. Our reviewer found that for CPT 95957, the technical report documents "Real time viewing and real time communication with technologist, surgeon, and anesthesiologist was maintained throughout procedure". This service is included in the intraoperative neuromonitoring procedure. Any additional testing would also be included in the intraoperative neuromonitoring procedure as well. For CPT 95908, the technical report does not document nerve conduction studies to include measurement of amplitued, latency and conduction velocity. Documentation supports subdermal needle electrodes, which is not considered nerve conduction. For CPT 95886 and 95887, the technical report does not include documentation of nerve conduction studies, which is included with these procedures. Therefore, these procedures would not be covered.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (95957, 95908, 95886, 95887) provided on October 7, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for lab services (87486, 87496, 87498, 87541, 87581, 87640, 87798, 87532) provided December 8, 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 codes 87486, 87496, 87498, 87541, 87581, 87640, 87798, & 87532 are not supported in the medical record. Specifically, the place of service on the claim (81, lab) does not match the place of service detailed in the records (13, 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 (87486, 87496, 87498, 87541, 87581, 87640, 87798, 87532) provided December 8, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (72125) provided September 25, 2020.

You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says insufficient documentation was provided to support the services billed.

The Plan must follow Medicare rules. Medicare rules say that the provider, supplier, or beneficiary, as appropriate, 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. No medical records were provided to support the claim. Based on this information, we decided that Medicare rules for coverage of the radiology services have not been met. Therefore, we decided that the Plan does not have to pay for radiology services (72125) provided September 25, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Rituxan (J9312).
You asked the Plan to pre-approve Rituxan. You say that this drug is medically reasonable and necessary for the enrollee's condition. The Plan denied your request. The Plan says Rituxan is not approved for chronic fatigue syndrome as it is currently considered investigational for this condition.
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 Rituxan. Our reviewer says that the requested drug services are not medically reasonable and necessary. Our physician reviewer found the enrollee is a 56-year-old male w/ Rai Stage 0 chronic lymphocytic leukemia (CLL) and small lymphocytic lymphoma (SLL), chronic fatigue syndrome, autonomic dysfunction, recurrent migratory multifocal myalgias, and severe psychiatric disorders (including severe mood disorder w/ prior suicidality and severe sleep disorders). The review indicates that Rituxan is currently investigational for chronic fatigue syndrome (CFS). Medicare guidelines (BKC 5.01.24.MA - Rituximab and Biosimilars-Medicare Advantage Only) allow for Rituximab when it is given in combination with fludarabine and cyclophosphamide (FC) for the treatment of individuals with previously untreated and previously treated CD20-positive CLL. Records from the provider indicate that Rituximab alone is primarily being recommended to treat chronic fatigue syndrome (CFS) and not the CLL. The review has determined that the documentation does not support that Rituxan is medically reasonable and necessary for the patient.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rituxan have not been met. Therefore, we decided that the Plan does not have to pre-approve Rituxan (J9312).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that you cannot go back home in your current condition
as you will be right back at the hospital. The Plan denied your request. The Plan says your records do not show
that you need three hours of therapy a day. The Plan states you can safely receive the services you need in other
settings, for example: a skilled nursing facility, home with home health services or home with outpatient
therapy.

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 your nursing, medical and rehabilitation needs does not require an
acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for
weakness and congestive heart failure. Medical problems are stable. There are no complex nursing or
rehabilitation needs. You do 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. 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 acute IRF admission and services.