Persius/hicric huggingface dataset:
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 a lower level of care would put the enrollee at risk for delayed progress. The Plan denied your request. The Plan says the enrollee's care is routine, and she does not need a team of providers.

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 physician reviewer found that the enrollee was admitted to the acute care hospital for a stroke and rhabdomyolysis. Her medical problems are stable. She does not require treatment by multiple therapies in an intensive rehabilitation therapy program. While she has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. 

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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the left elbow.  You asked the Plan to pre-approve the MRI. You say that the enrollee would benefit from this imaging to check for occult fracture or tendon injury. The Plan denied your request. The Plan says an MRI would not provide more information which would alter treatment.  The Plan must follow Medicare rules. Medicare rules say that MRIs 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 MRI. Our reviewer says that the requested MRI is not considered medically reasonable and necessary. Our physician reviewer found this 44-year-old female was being treated for pain in the left elbow. She presented with persistent symptoms despite anti-inflammatories, ice, compression, elevation, and home exercise program. Exam reveals no significant swelling. She does have tenderness to palpation directly over the posterior olecranon. She has excellent range of motion that is full. There is no significant discomfort with resisted elbow flexion or extension. X-rays from 7/15/21 show no acute fracture or dislocation; no significant soft tissue swelling is noted; no evidence of joint effusion.   The MRI was ordered due to concerns for residual left olecranon bursitis vs olecranon bony contusion. Provided documentation already demonstrates subjective and objective deficits and sufficient information to provide for a diagnosis and treatment options. Therefore, this request the request for MRI of the left elbow is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the left elbow.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ultrasound of the abdomen (76705) provided on September 30, 2021.  You asked the Plan to pay for the ultrasound of the abdomen. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this claim has not been billed with an appropriate modifier as required by Medicare rules.  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 76705 is a column II code to column I code 93976. 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 ultrasound of the abdomen (76705) provided on September 30, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pain management services provided on July 26, 2021.  You asked the Plan to pay for the services provided. You say that subarachnoid opioids have been found very effective. The Plan denied your request. The Plan says there are no clinical records to support medical necessity.  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 looked at the file and the rules. In this case, there are insufficient medical records to show that the services were medically reasonable and necessary to treat the enrollee. The file shows that the Plan made multiple attempts to obtain additional information with no success. 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 pain management services provided on July 26, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve routine, non-emergency transportation to be provided by the requested provider.  You asked the Plan to pre-approve routine, non-emergency transportation. You say that you are dissatisfied by the Plan's transportation provider. The Plan denied your request. The Plan says the Plan may only cover transportation provided by the Plan-approved transportation provider. 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 provided by the Plan-approved transportation provider.    We looked at your request, the records in the case file, and the rules. The requested transportation provider is not the Plan-approved transportation provider. 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 pre-approve routine, non-emergency transportation to be provided by the requested provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency anesthesia rendered on March 2, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.

The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Billed procedure code 99140 (emergency anesthesia) has a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the emergency anesthesia rendered on March 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 99203 billed for date of service May 18, 2021.  You asked the Plan to pay for procedure code 99203. You did not provide an argument with your appeal request. The Plan denied your request. The Plan says code 99203 is not separately payable when billed with codes 77263, 77290-26, and 77334-26 on the same date of service without an appropriate payment modifier appended.  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 99203 is a column II code to column I codes 77263, 77290-26, and 77334-26. 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 procedure code 99203 billed for date of service May 18, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the outpatient hospital services rendered from June 22, 2021,
to June 23, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your
request. The Plan says the services were not billed correctly.

The Plan must follow Medicare rules. The rules say that a hospital may attest to specific non-diagnostic
services as being unrelated to the hospital Part A claim by adding a condition code 51.

We looked at the file and Medicare rules. The file shows that the services were not billed with the required
condition code 51. Based on this information, we decided that Medicare rules for coverage of these services
have not been met. Therefore, we decided that the Plan does not have to pay for the outpatient hospital services
rendered from June 22, 2021, to June 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion/specialty drug administration (CPT code(s): 99601 and 99602) provided to the enrollee on July 1, 2021.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered by Medicare.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  CPT code(s): 99601 and 99602, have a status code of "I". Medicare guidance says status code "I" Not valid for Medicare purposes. Medicare uses another code for reporting of and payment for these services. 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 home infusion/specialty drug administration (CPT code(s): 99601 and 99602) provided to the enrollee on July 1, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM) and sensors.  You asked the Plan to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM) and sensors. You say that the items are medically necessary. The Plan denied your request. The Plan says you are not currently insulin treated.  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 and require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of a Freestyle Libre Continuous Glucose Monitor (CGM) and sensors have not been met. Therefore, we decided that the Plan does not have to pre-approve a Freestyle Libre Continuous Glucose Monitor (CGM) and sensors.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bifocal spectacle fitting rendered on February 12, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that Medicare does not cover routine vision services and eyewear.   The services you asked the Plan to pay for are considered routine vision services or eyewear. Therefore, we decided that the Plan does not have to pay for the bifocal spectacle fitting rendered on February 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Infuse allograft for the enrollee.  You asked the Plan to pre-approve these services. You say that this is medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of the Infuse Allograft in the setting of posterior cervical spine fusion surgery has not been demonstrated in the peer-reviewed literature.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Infuse BMP graft remains experimental in the posterior cervical spine. It was only FDA approved for anterior lumbar spine use in a cage. More research is needed. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve Infuse allograft for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided on July 13, 2021.

You asked the Plan to pay for the moderate sedation services. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says this claim has not been billed as required by Medicare coding regulations.

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 99153 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status. 

We find that payment for CPT code 99153 is not supported in the medical record. Specifically, CPT code 99153 is a technical component only code. The technical component will not be paid to the physician when performed in a facility setting. This means that payment for this service is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services provided on July 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for CT scan, thorax, diagnostic; without contrast material (CPT code 71250) provided on September 27, 2021.  You asked the Plan to waive the copayment for the CT scan. You say that you are appealing your cost-share responsibility for the services you received. The Plan denied your request. The Plan says the claim was processed accordingly with your 2021 EOC benefits.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance).  Review of the file shows that you received a thorax CT scan on September 27, 2021. You were asked to pay a $105 copayment for the CT scan. The 2021 health plan contract says that enrollees must pay a $105 copayment for Medicare-covered radiological diagnostic services, not including X-rays, performed in a physician's office or at a free-standing facility (such as a radiology center or medical clinic). 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 CT scan, thorax, diagnostic; without contrast material (CPT code 71250) provided on September 27, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the podiatry services, toenail trimming provided on September 1, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the podiatry services. You say that your primary care physician advised you that the service would not be covered under the Plan. You would like to know why the toenail clipping is no longer covered when it was covered before. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before 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 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 the podiatry services, toenail trimming provided on September 1, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on March 16, 2021.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.  The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.   We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 the lab services provided on March 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the subsequent hospital care rendered on September 28, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  The Plan must follow Medicare rules. The rules say that physicians in the same group practice who are in the same specialty must bill and be paid as though they were a single physician.      We looked at the file and Medicare rules. The file shows that billed procedure code 99231 (subsequent hospital care) was billed by a physician in the same group practice as a previously paid evaluation and management service and is not separately payable. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care rendered on September 28, 2021.
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 the enrollee is still inpatient, and the records provided support the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage of IRF care have not been met. The Plan says that the enrollee could receive care in another setting.  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 the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for hip fracture after a fall. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that the enrollee 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.