Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an oxygen concentrator. 
 
You asked the Plan to pre-approve an oxygen concentrator. You say that this is medically necessary. The Plan 
denied your request. The Plan says that no clinical information was available from your doctor including 
oxygen saturations readings or arterial blood gas results with this request. 
 
The Plan must follow Medicare rules. The rules say that oxygen is coverable when medically necessary for 
patients with significant hypoxemia who meet certain blood gas evidence requirements. In addition, the patient 
must have tried other alternative treatments without complete success. The patient must meet one of the 
following blood gas levels:  
1. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, at rest; 
 
2. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88% on room air, taken during 
sleep for a patient who have hypoxia symptoms during sleep; 
 
3. Arterial PO2 at or below 55 mm Hg or arterial O2 saturation at or below 88%, taken during exercise for 
patients who have hypoxia symptoms during exercise; 
 
4. Arterial PO2 between 56 and 59 mmHg and arterial O2 saturation is 89% on room air if there is evidence of 
dependent edema, pulmonary hypertension, or erythrocythemia. 
 
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 an oxygen concentrator. Our reviewer 
says that an oxygen concentrator is not medically reasonable and necessary. There is no clinical information 
available from your doctor including oxygen saturations readings or arterial blood gas results. There is 
insufficient clinical evidence provided in the records to conclude supplemental oxygen is medically necessary. 
Our physician reviewer found that your condition does not meet criteria for coverage of an oxygen 
concentrator. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of an oxygen concentrator have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an oxygen concentrator.
Appeal type: Lab
Decision: Partially Favorable

We decided that the Plan has to pay for the drug testing service billed with CPT code G0483. We decided that the Plan does not have to pay for the drug testing service billed with CPT code G0480 and the specimen handling service billed with CPT code 99000.
You asked the Plan to pay for the drug testing service billed with CPT code G0483. You say that you would like reconsideration based on the records submitted. The Plan says that an edit exists between CPT codes G0483 and G0480 and CPT code 99000 has a status indicator of B.
We decided that the Plan has to pay for the drug testing service billed with CPT code G0483.
The Plan follows Medicare rules. Medicare rules say that Medicare plans must make reasonable and diligent efforts to gather and forward information to the Independent Review Entity (IRE). We looked at the file and Medicare rules. Based on this information we have determined that Medicare criteria for coverage have been met. Specifically, the Plan has not forwarded any evidence as to why CPT code G0483 is not eligible for payment. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the Plan's denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the drug testing service billed with CPT code G0483.
We also decided that the Plan does not have to pay for the drug testing service billed with CPT code G0480 and the specimen handling service billed with CPT code 99000.
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly. We looked at the file and Medicare rules. Based on this information we have determined that Medicare criteria for coverage have not been met. Specifically, we have confirmed that CPT code G0480 is a column II code to column I code G0483 which was billed on the same claim. This code pair does not allow for modifier to bypass the edit. G0480 is not eligible for separate reimbursement in this case. Additionally, CPT code 99000 has a status indicator of B. This means that the payment for CPT code 99000 is bundled into the payment for another procedure or service. Therefore, we decided that the Plan does not have to pay for the drug testing service billed with CPT code G0480 and the specimen handling service billed with CPT code 99000.
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 chiropractic visits provided on February 8, 2021, to June 23, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the chiropractic visits. You say that you are appealing the claims. You say that the therapy was a gift. The Plan denied your request. The Plan says no prior authorization was obtained.
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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for chiropractic visits provided on February 8, 2021, to June 23, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a removal of brain lesion (61510) provided on August 3, 2021.
You asked the Plan to pay for a removal of brain lesion. You say that the service at issue was a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because the CPT code at issue is inclusive to another billed code (61545, Excision of craniopharyngioma).
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 61510 is "Craniectomy, trephination, bone flap
craniotomy; for excision of brain tumor, supratentorial, except meningioma." 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 a removal of brain lesion. Our reviewer says that the CPT code at issue does not meet criteria for payment. Our reviewer found that the provided operative report in this case describes that only one tumor was excised. Documentation does not support two tumors excised, and therefore only an excision of craniophyaryngioma (61545) is supported. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a removal of brain lesion have not been met. Therefore, we decided that the Plan does not have to pay for a removal of brain lesion (61510) provided on August 3, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from September 10, 2021, to October 9, 2021.
You asked the Plan to pay for the services. You say that this is medically necessary. The Plan denied your request. The Plan says daily skilled services on an inpatient basis were not required.
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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from September 10, 2021, to October 9, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
You asked the Plan to pre-approve 12 additional physical therapy visits. You say that the physical therapy sessions are necessary. The Plan denied your request. The Plan says 12 physical therapy sessions have been approved and an additional 12 could be reassessed after the initial 12 are completed.
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy. 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 12 additional physical therapy visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of your condition. Our physician reviewer found that the additional 12 requested therapy sessions are not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan at this time without reassessment after the initial authorized 12 visits. You have had prior therapy and were approved for 12 more visits. Without the outcome of the recently approved visit it is not possible to determine that the ongoing unique skills of a professional therapist are required to safely and effectively provide treatment, or that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program already. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 12 additional physical therapy visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 12 additional physical therapy visits.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for an implant maintenance procedure when prostheses are removed and reinserted (D6080) provided on July 21, 2021.
You asked the Plan to pay for an implant maintenance procedure. You say that your dentist recommended you have your implants cleaned and scaled. You also say you were surprised the services were denied as you have spent thousands of dollars on your implants and your insurance pays for a tooth cleaning every six months. You believe implants should be included for your teeth cleaning benefit. The Plan denied your request. The Plan says the requested service is not covered by the preventative dental benefit.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for an implant maintenance procedure when prostheses are removed and reinserted (D6080) provided on July 21, 2021.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to reduce the copayment for transthoracic echocardiography with image documentation (93306) provided on October 11, 2021.
You asked the Plan to reduce the copayment for the echocardiography. You say that this was just a regular echo and should only be billed with a $35 diagnostic copayment. The Plan denied your request. The Plan says that this claim was processed correctly, and your copayment was assessed in accordance with your contract. You are responsible for a $400 copayment for outpatient surgery services provided in an outpatient hospital facility.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $35 copayment for other outpatient diagnostic tests provided by a specialty physician. The Plan says you must pay a $400 copayment for the echocardiography, and states that you are responsible for this copayment for outpatient surgery provided in a hospital setting. However, the service at issue, billed with procedure code 93306, is not classified as a surgical procedure. Based on the Plan contract, you cannot be asked to pay more than a $35 copayment for echocardiography provided by a specialist physician. Therefore, we decided that the Plan has to reduce the copayment for transthoracic echocardiography with image documentation (93306) provided on October 11, 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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided August 24, 2021 to September 22, 2021.
You asked the Plan to pay for the SNF services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says the Medicare criteria for SNF level of coverage were not met.
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 there are no identifiable skilled nursing and skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis and does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting.
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 August 24, 2021 to September 22, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of a spinal cord stimulator.
You asked the Plan to pre-approve spinal cord stimulator. You say that the enrollee is planning to have a spinal cord stimulator implanted to manage her pain. The Plan denied your request. The Plan says the enrollee does not meet any of the coverage indications for a spinal cord stimulator.
The Plan follows Medicare rules. Medicare rules state that spinal cord stimulators may only be covered for certain 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 spinal cord stimulator. Our reviewer says that the enrollee does not meet the Medicare criteria for a spinal cord stimulator. Our physician reviewer found the enrollee does not have an evidence-based indication for a spinal cord stimulator trial. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of spinal cord stimulator have not been met. Therefore, we decided that the Plan does not have to pre-approve use of a spinal cord stimulator.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (88341, 85097, 88305, 88365) provided on September 22, 2021.
You asked the Plan to pay for laboratory services. You say that this was billed with a valid diagnosis. The Plan denied your request. The Plan says this was not billed with an appropriate primary diagnosis.
The Plan must follow Medicare rules. Medicare rules say that certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) has a coding convention that requires the underlying condition be sequenced first, if applicable, followed by the manifestation.
We looked at the file and Medicare rules. The first-listed and only diagnosis billed on the claim, D75.81, is a manifestation code that requires the underlying condition to be sequenced first. Based on this information, we decided that Medicare rules for coverage of laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services (88341, 85097, 88305, 88365) provided on September 22, 2021.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for drug testing (G0482) provided on September 21, 2021. 
 
You asked the Plan to pay for drug testing. You say that this is supported in the records. The Plan denied your 
request. The Plan says this was not billed correctly. 
 
The Plan must follow Medicare rules. Medicare rules say that if an independent lab bills for services, the place 
where the sample was taken is reported as the Place of Service (POS).  
 
We looked at the file and Medicare rules. The testing at issue was billed with POS 81 for an independent 
laboratory, but the record shows that the sample was not taken in the laboratory. Based on this information, we 
decided that Medicare rules for coverage of drug testing have not been met. Therefore, we decided that the Plan does not have to pay for drug testing (G0482) provided on September 21, 
2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99223) provided on September 20, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not payable.
The Plan must follow Medicare rules. Medicare rules say that if more than one evaluation and management (face-to-face) service is provided on the same day to the same patient by the same physician or more than one physician in the same specialty in the same group, only one evaluation and management service may be reported. We looked at the file and Medicare rules. The E/M services in question were provided on the same day as E/M services (99232) provided by a provider of the same specialty within the same group practice. This means that only E/M service is payable. As code 99232 has already been processed and paid by the Plan, code 99223 is not payable in this case. 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 (99223) provided on September 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve low dose computed tomography (LCCT) for lung cancer 
screening for the enrollee. 
 
You asked the Plan to pre-approve the scan. You say that the doctor would like to screen for disease in the 
lungs. The Plan denied your request. The Plan says there is no written order. 
 
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 scan. Our reviewer says that the 
requested scan is not medically reasonable or necessary. Our physician reviewer found this current smoker had 
a low dose CT scan for lung cancer screening on 7/21/21 that showed 2 pulmonary nodules. At this point a 
repeat CT would be indicated for follow-up on these and would not be for screening but diagnostic. Low dose 
CT for screening is done annually. The wrong type of CT is being ordered for this patient who should have a 
regular lung CT for follow-up of nodules. The service is not reasonable or 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 scan have not been met. Therefore, we decided that the Plan does not have 
to pre-approve low dose computed tomography (LCCT) for lung cancer screening for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on October 5, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a domiciliary or rest home visit (99336). You say that it is the nursing facility's responsibility to get authorization for their patients. You also say that it was medically necessary for the patient to receive the treatment by this provider, and you did not know that the facility failed to get preauthorization for this patient. The Plan denied your request. The Plan says prior authorization is required from the Plan for this disputed service to be covered. The Plan also says that an authorization was not obtained prior to the services being rendered and the provider is not participating with the member's Plan.
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 a domiciliary or rest home visit (99336) provided on October 5, 2021, by an out-of-network (OON) provider.