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

We decided that the Plan does not have to pay for the inpatient hospital care provided from March 12, 2021,
through March 19, 2021, billed with secondary diagnosis code J96.01.

You asked the Plan to pay for the inpatient services as billed. You say that the records support this diagnosis
and the DRG payment should not be reduced. The Plan denied your request. The Plan says the secondary
diagnosis is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the
reported principal and secondary diagnosis codes.

In this case, you billed the inpatient services provided with secondary diagnosis code J96.01, defined as acute
respiratory failure with hypoxia. 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 inpatient
services as billed. Our reviewer says that the documentation does not support the inclusion of J96.01 as a
secondary diagnosis for this hospital stay. Our physician reviewer found the documentation shows that the
enrollee was brought to the hospital after an episode of syncope. She also had recent medical history of
pneumonia and bradycardia. She reported mild shortness of breath for the past week prior to presentation. The
nurse assessment noted labored breathing, respiratory distress, wheezing, and rales with oxygen levels at 94%.
Work-up in the emergency room demonstrated leukocytosis and bilateral pneumonia on imaging, and the
patient was subsequently admitted for further evaluation for pneumonia (and additionally, for evaluation of an
ovarian cyst).

There was no documentation of treatment consistent with acute respiratory failure with hypoxia, which would
include administration of oxygen at five liters per minute or more, or provision of bilevel positive airway
pressure (BiPAP) and/or mechanical ventilation. The review has determined that the records did not support the
reporting of secondary diagnosis code J96.01 (acute respiratory failure with hypoxia).

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the
medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay
for the inpatient hospital care provided from March 12, 2021, through March 19, 2021, billed with secondary
diagnosis code J96.01.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve scout option (K0108) and under seat storage basket (K0108).  You asked the Plan to pre-approve the wheelchair components or accessories. You say that you request that the enrollee's request for a stroller type manual wheelchair be re-examined. The Plan denied your request. The Plan says these items do not meet the coverage criteria.  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. In this case the scout option turns the cruiser into an all-terrain, special needs stroller. This is not a feature needed for use within the home. The under-seat storage option does not primarily and customarily serve a medical purpose. Based on this information, we decided that Medicare rules for coverage of the wheelchair components or accessories have not been met. Therefore, we decided that the Plan does not have to pre-approve scout option (K0108) and under seat storage basket (K0108).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Rexuience (Rituxan).  You asked the Plan to pre-approve Rexuience (Rituxan). You say that this drug is medically necessary for your condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer drugs if they are medically accepted as safe and effective or appropriate for the particular use.   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 Rexuience (Rituxan). Our reviewer says that this request is not medically reasonable and necessary. Our physician reviewer found you have been diagnosed with extramedullary plasmacytoma of the stomach with immunoglobulin A deficiency. In this case, the requested drug is not FDA-approved for your condition. In addition, the use of this drug is not supported by one of the major drug compendia or by clinical research that appears in a Medicare-approved medical journal.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Rexuience (Rituxan) have not been met. Therefore, we decided that the Plan does not have to pre-approve Rexuience (Rituxan).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that you need more extensive rehabilitation than you are getting now. The Plan denied your request. The Plan says the denial of authorization for IRF care is correct.  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. While you may need physical and/or occupational therapy, there is no documented need for an intensive 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a stair lift.

You asked the Plan to pre-approve a stair lift. You say that a representative of the Plan told you the mechanism at issue would be covered. The Plan denied your request. The Plan says the requested item is not a covered benefit.

The Plan covers all items that Medicare covers. Medicare rules state that stair lifts are not covered because they are not primarily medical in nature. While a stair lift may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a stair lift.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 2 standard power operated vehicle (K0806).

You asked the Plan to pre-approve a Group 2 power operated vehicle. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met for the requested item.

The Plan must follow Medicare rules. Medicare rules say that if a Group 2 POV is provided it will be denied as not reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of a Group 2 power operated vehicle have not been met. Therefore, we decided that the Plan does not have to pre-approve a Group 2 standard power operated vehicle (K0806).
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Prochlorperazine for the enrollee.

You asked the Plan to pre-approve this drug. You say that this is medically necessary. The Plan denied your request. The Plan says that this is not covered under Part B.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Prochlorperazine for the enrollee.

Benefits for this drug may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the retreatment of a previous root canal (D3348) provided by an out-of-network provider on October 6, 2021.  You asked the Plan to pay for the retreatment of a previous root canal. You say that you would like the Plan to pay for this. The Plan denied your request. The Plan says the dental work that was provided is not a covered 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 the retreatment of a previous root canal (D3348) provided by an out-of-network provider on October 6, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from March 27, 2019, to March 29, 2019.  You asked the Plan to pay for the self-administered drugs. You say that the enrollee received the same drugs on this date of service as another stay. You also say that the enrollee was not charged for these services during their other stay. The Plan denied your request. The Plan says the drugs you received are considered self-administered.   The Plan says self-administered drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the drugs you received are not covered under Medicare Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pay for the self-administered drugs provided in an outpatient setting from March 27, 2019, to March 29, 2019.   Benefits for the self-administered drugs may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the routine disposable supplies (A0398) provided on October 13, 2021.  You asked the Plan to pay for the supplies. You say that you cannot pay for this service. The Plan denied your request. The Plan says this service/item is not a Medicare covered benefit and excluded from coverage under your plan.  The Plan must follow Medicare rules. Medicare rules say that an ambulance must have customary patient care equipment and first aid supplies, including reusable devices and equipment such as backboards, neckboards, inflatable legs, and arm splints. These are all considered part of the general ambulance service and payment for them is included in the payment rate for the transport.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the supplies have not been met. Therefore, we decided that the Plan does not have to pay for the routine disposable supplies (A0398) provided on October 13, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rest home visit (99336) provided on July 26, 2021 by an out-of-network (OON) provider.    You asked the Plan to pay for the evaluation and management service. You say that the facility requests your providers to see their patients. You say that you should fall under their authorization if on is needed. You also say that the services were performed in good faith. The Plan denied your request. The Plan says authorization was not obtained prior to the services being rendered.  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 the in network rate 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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay the in network rate for these items/services. Therefore, we decided that the Plan does not have to pay for the rest home visit (99336) provided on July 26, 2021 by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for dental services provided by an opt-out provider on July 14, 2021.  You asked the Plan to pay for dental services. You say that you believe that the Plan should pay for this. The Plan denied your request. The Plan says the rendering dentist has opted-out of Medicare.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. The provider has opted-out until February 17, 2022. Therefore, we decided that the Plan does not have to pay for dental services provided by an opt-out provider on July 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for magnetic resonance angiography, head (70544) provided September 28, 2021.  You asked the Plan to pay for the diagnostic service. You say that medical records were attached to support the services rendered. The Plan denied your request. The Plan says this service is bundled to another service, billed on the same day, by the same provider.  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 70544-26 is a column II code to column I code 70551-26. 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 magnetic resonance angiography, head (70544) provided September 28, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the subarachnoid opioid injection provided on October 4, 2021.

You asked the Plan to pay for the subarachnoid opioid injection. You say that this was denied as an epidural steroid injection, but this was a subarachnoid opioid injection, which is medically necessary and should be covered. The Plan denied your request. The Plan says records were not submitted to support medical necessity.

The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. No records were submitted to confirm the services rendered, nor to support that coverage criteria have been met. Therefore, we decided that the Plan does not have to pay for the subarachnoid opioid injection provided on October 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) scan of the lower spinal canal.  You asked the Plan to pre-approve MRI scan services. You say that this procedure is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the criteria for coverage have not been met.  The Plan must follow Medicare rules. The 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. In this case, the Plan requested medical records several times that would support that the criteria for coverage have been satisfied. However, no medical records were returned. Without these medical records, we cannot determine the medical necessity of the requested imaging service. Based on this information, we decided that Medicare rules for coverage of MRI scan services have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) scan of the lower spinal canal.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foot orthotics, shoe lifts tapered to one-half (L3332).  You asked the Plan to pre-approve foot orthotics. You say that you are unable to walk normally without a shoe lift. You would like to have a custom lift as without the lift you are having pain. The Plan denied your request. The Plan says this item is not a covered benefit.  Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules.    Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics, shoe lifts tapered to one-half (L3332).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554) and related supplies (K0553).  You asked the Plan to pre-approve a continuous glucose monitor and related supplies. You say that the requested item is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage for continuous glucose monitors and related supplies have not been met.  The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.  We looked at the file and Medicare rules. The documentation indicates that the enrollee does not use insulin with at least three daily injections. Based on this information, we decided that Medicare rules for coverage of a continuous glucose monitor and related supplies have not been met. Therefore, we decided that the Plan does not have to pre-approve a continuous glucose monitor (K0554) and related supplies (K0553).
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code A9516 billed for date of service August 10, 2021.  You asked the Plan to pay for procedure code A9516. You say that this patient had multiple exams on this date of service, so this code should be paid. The Plan denied your request. The Plan says no modifier was billed on this claim to permit payment of this code.  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 A9516 is a column II code to column I code 78803. 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 procedure code A9516 billed for date of service August 10, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for the therapeutic procedures (97110) provided on December 16, 2020.  You asked the Plan to pay for the therapeutic procedures. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a more appropriate CPT code to bill for the services rendered.   The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. The rules also say that the services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist.   We find that CPT code 97110 is not supported in the record. Specifically, this claim was billed by a Nurse Practitioner and the records indicate that the services were rendered by a PTA. Nurse Practitioners are not able to bill for the services of a PTA because they do not meet the qualifications of a therapist. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedures have not been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedures (97110) provided on December 16, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Magnetic resonance angiography (70544) provided on September 25, 2021.  You asked the Plan to pay for code 70544. 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 as 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, we have confirmed that code 70544 is a column II code to column I code 70551. 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 the Magnetic resonance angiography (70544) provided on September 25, 2021.