Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the services (99214-25) provided on March 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says that modifier -25 is not appropriate.
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 Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has failed to provide information regarding the other services rendered on this date of service. In addition, the denial rationale states that the Plan does not follow Medicare billing rules, which is not an appropriate rationale for a Medicare Advantage plan as they are required to make payment for services that Original Medicare would pay for, according to Medicare billing rules. We find that the Plan has not substantiated that the use of modifier -25 was inappropriate in this case. Therefore, we decided that the Plan has to pay for the services (99214-25) provided on March 26, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for diabetic shoes with inserts on December 30, 2020.
You asked the Plan to pay for the diabetic shoes with inserts. You say that you did not realize that you only could get one pair per year. The Plan denied your request. The Plan says the benefits only one pair per plan year of diabetic shoes with inserts fitting.
The Plan must follow Medicare rules. Medicare rules say that health plan must disclose to its enrollees in clear, accurate terms all cost sharing information such as copayments, coinsurance, and deductibles. The EOC says only one pair of diabetic shoes with inserts is payable per year. You already obtained a pair in February of 2020. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the diabetic shoes with inserts have not been met. Therefore, we decided that the Plan does not have to pay for diabetic shoes with inserts on December 30, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of SNF care from October 24, 2021, 
forward. 
 
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 at the time of admission, the enrollee required 
skilled rehabilitation services to improve function due to weakness and deconditioning.  There were no skilled 
nursing needs.  
 As of October 23, 2021, the enrollee did not require any skilled nursing or rehab services on a daily basis. The 
enrollee 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 activities of daily living (ADLs). The enrollee 
did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, the 
enrollee did not require any skilled services on an inpatient basis, at a SNF level of care as of October 23, 2021. 
The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube.  

The enrollee received skilled care and improved; however, her function had plateaued and then declined by 
October 23, 2021, and the enrollee did not require any further inpatient skilled rehabilitation services. The 
enrollee's function was at or near their prior level of function and the enrollee could be discharged to a lower 
level of care for further services. As of October 23, 2021, the enrollee required custodial services. The denial 
for further inpatient skilled care is upheld. 
 
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 continuation of SNF care from October 24, 2021, forward.
Appeal type: Surgery
Decision: Favorable

We decided that the Plan has to pre-approve multiple venous procedures intravascular ultrasound followed by angioplasty and stenting with sedation (CPT code(s): 76937, 75820, 99152, 99153, 75822, 37252 X 2, 36012 X 4, and 37253), for the enrollee.
You asked the Plan to pre-approve the services. You say that the enrollee has persistent swelling and pain that is worse on their left side. You state the enrollee's pain is affecting their ability to do daily activities. The Plan denied your request. The Plan says that the enrollee does have signs and symptoms consistent with venous insufficiency, but not iliac vein compression. The Plan states the enrollee has had no surgical treatment for venous insufficiency. The Plan states the enrollee has not had initial testing such as computed tomographic (CT) or magnetic resonance (MR) venography.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is medically necessary. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the services. Our reviewer says that the requested items/services are considered medically reasonable and necessary in this case. Our physician reviewer found the documentation supports the medical necessity of the intervention in question. The enrollee has a history of bilateral leg symptoms with documented severity and documented recurrent episodes of phlebitis. The enrollee has documentation of bilateral leg edema and persistent issues despite numerous interventions on the superficial leg veins. Satisfactory arterial perfusion to the lower extremities has been documented as well. In this case it would be reasonable to investigate whether there is a component of iliac vein occlusive disease and treat accordingly. 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 services have been met. Therefore, we decided that the Plan has to pre-approve multiple venous procedures intravascular ultrasound followed by angioplasty and stenting with sedation (CPT code(s): 76937, 75820, 99152, 99153, 75822, 37252 X 2, 36012 X 4, and 37253), for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a computer-assisted navigational procedure (61783) provided on November 5, 2020.
You asked the Plan to pay for a computer-assisted navigational procedure. You say that this was medically necessary. The Plan denied your request. The Plan says this is not separately payable.
The Plan must follow Medicare rules. Medicare rules say that services with status indicator N are paid under the Outpatient Prospective Payment System (OPPS), but their payment is packaged into payment for a separately paid service. We looked at the file and Medicare rules. Code 61783 has a status indicator of N, meaning payment for this service is packaged into payment for other services. Based on this information, we decided that Medicare rules for coverage of a computer-assisted navigational procedure have not been met. Therefore, we decided that the Plan does not have to pay for a computer-assisted navigational procedure (61783) provided on November 5, 2020.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that you cannot do everyday functions. The Plan denied 
your request. The Plan says you can be treated at a lower level of care. 
 
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 the records show that you do not have skilled 
nursing needs. While you need therapy services, you do not need them on a daily 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 16, 2021.
You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.
The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for out of network physician services provided to the enrollee on April 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve laser assisted limbo-relaxing eye incision (CPT code 
S9986).  
You asked the Plan to pre-approve the services. You say that you are requesting review of denial of services. 
The Plan denied your request. The Plan says the service is not covered.  
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. We looked at the file, and Medicare rules. Based on this information, we decided 
that Medicare rules for coverage of the services have not been met. According to the records this service is not 
covered. The CPT code has a status indicator of "I" and Medicare guidance says status code "I" Not valid for 
Medicare purposes. Medicare uses another code for reporting of and payment for these services. Therefore, we 
decided that the Plan does not have to pre-approve laser assisted limbo-relaxing eye incision (CPT code 
S9986).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (72156) provided on June 10, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 72156 is "Magnetic resonance (eg, proton) imaging, spinal canal and contents, without contrast material, followed by contrast material(s) and further sequences; cervical".
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 code 72156 is not supported by the records provided. Our reviewer found that the records document interpretation of cervical MRI neurography. Therefore, this service cannot be confirmed as performed. 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 (72156) provided on June 10, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the laboratory services rendered on January 8, 2021.
You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the coinsurance was 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 40% coinsurance for out-of-network laboratory tests.
Review of the file shows that you received laboratory services from an out-of-network provider on January 8, 2021. You have been asked to pay a 40% coinsurance for these services. These services fall within the out-of-network laboratory tests 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 laboratory services rendered on January 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to waive the coinsurance for wound care supplies provided on May 19, 2021.
You asked the Plan to waive the coinsurance for wound care supplies. You say that a representative of the Plan advised you not to pay the bill in question. The Plan denied your request. The Plan says the correct coinsurance was applied.
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 20% coinsurance for Medicare-covered durable medical equipment. You have been asked to pay $21.53, or 20% of the Medicare-allowed charge of $107.67, for wound care supplies. Wound care supplies fall within the "Durable medical equipment (DME) and related supplies" 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 wound care supplies provided on May 19, 2021.
Your complaint about receiving erroneous or incomplete information from a representative of the Plan about your cost-sharing responsibilities is not a valid appeal for medical coverage. This part of your complaint is a grievance that must be answered by the Plan. Medicare does not permit us to make a decision about these types of complaints.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound care services (procedure codes 11043, 11046) provided to the enrollee on June 22, 2021.
You asked the Plan to pay for the services. You say that the infection was extensive, and a second debridement surgery was needed after the initial emergency surgery. The Plan denied your request. The Plan says payment is not allowed for this service.
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 the denied codes is: CPT 11043: Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); first 20 sq cm or less
CPT 11046: Debridement, muscle and/or fascia (includes epidermis, dermis, and subcutaneous tissue, if performed); each additional 20 sq cm, or part thereof (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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found billing CPT 11043 with modifier 78 is not supported by the documentation. The services provided on June 14, 2021 include anesthesia and arterial catheter which does not support wound care provided on this date of service. Therefore, modifier 78 would be inappropriate to report, as there was no initial procedure reported. CPT 11046 is considered and add on code. Per CPT AMA "All add on codes are modifier 51 exempt. 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 wound care services (procedure codes 11043, 11046) provided to the enrollee on June 22, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided the Plan does not have to waive the $250 copayment for an ambulance transport.
You asked the Plan to waive this copayment. You say that you do not believe you should have to pay this
copayment. The Plan denied your request. The Plan says this copayment is a contractual obligation.
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 for each one-way ambulance transport. 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 $250 copayment for an ambulance
transport provided on June 4, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve SNF services.
You asked the Plan to pre-approve SNF services. You say that you are a high risk for falling and you need additional therapy. The Plan denied your request. The Plan says your record does not show that you require daily skilled nursing or skilled therapy in a SNF setting. The services you require are custodial care.
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 services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found that based on the documentation provided, you do not qualify for SNF coverage. You do not have documented skilled nursing needs. You do not have documented skilled therapy needs. You have been recommended for home discharge with intermittent supervision. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (36415, 80053, 82533, 80061) provided on April 27, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for laboratory services. You say that this was medically necessary. The Plan denied your request. The Plan says this was not 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 items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for laboratory services (36415, 80053, 82533, 80061) provided on April 27, 2021, by an out-of-network (OON) provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide non-emergent routine medical transportation. 

You asked the Plan to provide non-emergent medical transport. You say that these services are necessary as 
you are currently wheelchair bound and require a wheelchair van to transport you to your physical therapy 
sessions. The Plan denied your request. The Plan says the necessary physician certification statement form 
must be provided in order to approve these services and verify medical necessity. Multiple outreach attempts to 
your provider were made, but the documentation has not been submitted. 
 
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a 
transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this 
case. The Plan covers routine transportation when the services are deemed medically necessary and supported 
by a completed physician certification statement.  
 
We looked at your request, the records in the case file, and the rules. No physician certification statement was 
provided with this request. Based on this information, we decided that the Plan's rules for coverage of routine 
transportation have not been met. Therefore, we decided that the Plan does not have to provide non-emergent 
routine medical transportation.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (15570) provided on January 8, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code 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 15570 is "Formation of direct or tubed pedicle, with or without transfer; trunk". 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 code 15570 is not supported by the records provided.
Our reviewer found that the operative report does not describe a pedicle flap made by elevating a long strip of tissue from its bed except at the two extremities which maintains vascular ends, the cut edges then being sutured together to form a tube. Therefore, this procedure cannot be confirmed. 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 (15570) provided on January 8, 2021.