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

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from January 27, 2020, to January 29, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the DRG was adjusted and recouped in this case.

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 DRG 871 (SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC). 

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 the services at issue in this case were not supported by the medical records. Our physician reviewer found the reviewed documentation supported an admission for pneumonia. From the information that was received, documentation was inconsistent/unclear regarding a diagnosis of severe sepsis. Even though severe sepsis is documented in the history and physical, progress note, and discharge summary, supporting medical record documentation was not found within the record. There was no evidence of a systemic, life-threatening organ dysfunction due to a dysregulated host response to infection, defining sepsis. The review has determined that DRG 194: SIMPLE PNEUMONIA AND PLEURISY WITH CC is the appropriate DRG for this case. 

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 inpatient hospital services provided to the enrollee from January 27, 2020, to January 29, 2020.
Appeal type: SNF
Decision: Partially Favorable

We decided that the Plan has to pay for the services received on July 17, 2021 and July 18, 2021. We decided that the Plan does not have to pay for the services received from July 7, 2021, to July 16, 2021 and the services received from July 19, 2021, to August 5, 2021.
You asked the Plan to pay for the services. You say that this should be paid for. The Plan says that there no major reported skilled needs or services to support approval of the SNF setting.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.  You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee appears to be experiencing chronic symptoms without immediate need for acute care and the infection appears to be appropriately treated at the skilled nursing facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered when treatment has completed.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the orthosis rendered on May 6, 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 there is no valid order.
The Plan must follow Medicare rules. Medicare rules say that a standard written order (SWO) is required for all durable medical equipment (DME) and supplies.
We looked at the file and Medicare rules. The file shows that there is no valid SWO supporting the billed supplies. Therefore, we decided that the Plan does not have to pay for the orthosis rendered on May 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve endovenous radiofrequency ablation services.

You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says your vein diameter is larger than the acceptable maximum.

The Plan follows Medicare rules. Medicare rules say that the treatment of varicose veins is only covered under certain medical 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 the requested services. Our physician reviewer found that you have already undergone two ablations on that leg. You have a history of lymphedema and has been referred for a lymphedema pump. There is documentation that you are doing well with the lymphedema pump and have no concerns. There is no satisfactory documentation that you are having lifestyle limiting pain as result of varicose veins. Additionally, a duplex confirming the absence of deep vein thrombosis, the presence of reflux in the area of symptoms, and a demonstration of anatomy amenable to the treatment plan (including appropriate vein measurement) has not been provided. The documentation does not meet coverage criteria and does not support the medical necessity of the treatment in question. 

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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve endovenous radiofrequency ablation services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the molecular genetic screening testing provided on August 31, 2021.
You asked the Plan to pay for the molecular genetic screening testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.
The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. Review of the file shows that there was no documented result of a prior prostate biopsy. There was no documented significant interval increase in prostate-specific antigen level. This means the molecular genetic screening testing at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the molecular genetic screening testing provided on August 31, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment and coinsurance for imaging services and injections provided on September 23, 2021.  You asked the Plan to waive the copayment and coinsurance for the imaging services and injections. You say that you had no knowledge these services would not be covered especially for the amount of the bill. The Plan denied your request. The Plan says the proper copayment and 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 a 20% coinsurance for Medicare Part B chemotherapy and non-chemotherapy prescription drugs and a $325 copayment for other Medicare-covered diagnostic radiology services that are not ultrasounds. The total amount charged for the injections was $244.31 with a coinsurance of $48.86 ($244.31 total amount x 20% coinsurance). The total copayment amount was $325. The total cost share for the date of service was $373.86 ($48.86 coinsurance + $325 copayment).  You have been asked to pay a $325 copayment for imaging services and a 20% coinsurance for injections. The imaging services falls within the Outpatient diagnostic tests and therapeutic services and supplies benefit category. The injections falls within Medicare Part B prescription drugs 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 and coinsurance for imaging services and injections provided on September 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the targeted case management (T1017) rendered by the out-of-network (OON) provider on September 4, 2021.
You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network
provider, without prior authorization.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. 
We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan
does not have to pay for the targeted case management (T1017) rendered by the out-of-network (OON)
provider on September 4, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the deductible for an office visit provided on October 5, 2021.
You asked the Plan to waive the deductible for the office visit. You say that the services should be covered.
The Plan denied your request. The Plan says the deductible applied correctly based on the services provided.
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 there is a $750 deductible which applies to Physician/Practitioner services,
including doctor's office visits. The item or service you asked the Plan to waive the deductible for falls within the benefit category
Physician/Practitioner services, including doctor's office visits. The Plan has followed Medicare rules by
clearly disclosing in the contract that there is a $750 deductible which applies to Physician/Practitioner
services, including doctor's office visits. This cost sharing is a contractual obligation that had not been met at
the time the office visit was received on October 5, 2021. Therefore, we decided that the Plan does not have to
waive the deductible for an office visit provided on October 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the Sanexas device and vitamin injections (96372, 97016,
97112, 97750, G0283, J3411, J3415, J3490, and J7999) provided on August 10, 2021.
You asked the Plan to pay for the Sanexas device and vitamin injections. The Plan denied your request. The
Plan says Medicare does not cover Prolotherapy.
The Plan must follow Medicare rules. Medicare rules state that in order for physician-provided drugs to be
covered, the medical records must document the name of the drug administered as well as the dosage. The rules
also say that Medicare Part B pays for outpatient physical therapy services only if they are furnished by, or
under the direct supervision of a physical therapist in private practice; or by, or incident to the service of a
nurse practitioner (NP) or physician assistant (PA) only when that NP/PA may perform physical therapy
services under State law.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the Sanexas device and vitamin injections have not been met. Payment for Healthcare Common
Procedure Coding System (HCPCS)/Current Procedural Terminology (CPT) codes 96372 and J3411, J3415,
J3490, J7999 are not supported. Specifically, the record does not contain documentation of the dosage and type
of drug administered in each injection, which is required by Medicare for these services to be reimbursed.
Additionally, review of the file and publicly available records, we find that the physical therapy services at
issue in this case were rendered by an NP who is not licensed to provide physical therapy in the State of
Oklahoma. Therefore, we decided that the Plan does not have to pay for the Sanexas device and vitamin
injections (96372, 97016, 97112, 97750, G0283, J3411, J3415, J3490, and J7999) provided on August 10,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for prolotherapy, a transcutaneous electrical nerve stimulator (TENS) and supplies, and a pneumatic device; examinations before, during and/or after treatment provided to the enrollee on June 17, 2021.  You asked the Plan to pay for the prolotherapy services billed. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says these services are not covered by the Plan or 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. Medicare rules say outpatient physical therapy services are subject to the criteria listed in the Medicare rules section. Medicare rules say compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code.  We find that the denied therapy services are not supported in the medical record. Specifically, we find that the physical therapy services (97112, G0283) at issue in this case were rendered by an NP/PA who is not licensed to provide physical therapy in the state the services were performed.  Additionally, the multiple drug codes reported on this claim (J3411, J3415, J3490, J7999) refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid.  Based on this information, we decided that Medicare rules for coverage of the prolotherapy services billed have not been met. Therefore, we decided that the Plan does not have to pay for prolotherapy, a transcutaneous electrical nerve stimulator (TENS) and supplies, and a pneumatic device; examinations before, during and/or after treatment provided to the enrollee on June 17, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on June 3, 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 laboratory shall not report multiple individual CPT codes describing the component test results.   

We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 3, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the psychotherapy services rendered on June 9, 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 a clinical psychologist must have a referral and consult from the beneficiary's primary care physician (PCP).  We looked at the file and Medicare rules. There is no documentation of a referral and consult from the enrollee's PCP. 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 psychotherapy services rendered on June 9, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the foot insert (L3020).
You asked the Plan to pay for foot orthotics. You say that you need this item. 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 pay for the foot insert (L3020).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Lidocaine injection provided on November 24, 2020.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says an
appropriate modifier was not billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.
The file shows that CPT code J2001 was billed with code 62323. We find that CPT code J2001 may be eligible
for payment when billed with this code pair. The claim does not show that code J2001 was billed with a
modifier suitable for payment. 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
Lidocaine injection provided on November 24, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the Intravenous (IV) tubing extension (S1015) and infection control supplies (S8301) provided on August 11, 2021.

You asked the Plan to pay for the IV tubing extension and infection control supplies. You say that you would like reconsideration because you supplied, at your own cost, all of the anesthesia equipment, medication and supplies to support the member during their procedure. The Plan denied your request. The Plan says the billed CPT codes are not valid for 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.

We find that CPT codes S1015 and S8301 are not supported in the record. Specifically, CPT codes S1015 and S8301 have a status indicator of I. This means that CPT codes S1015 and S8301 are not valid for Medicare. Based on this information, we decided that Medicare rules for coverage of the IV tubing extension and infection control supplies have not been met. Therefore, we decided that the Plan does not have to pay for the Intravenous (IV) tubing extension (S1015) and infection control supplies (S8301) provided on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve office or other outpatient visit (99203) to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve office or other outpatient visit. You say that you do not wish to receive care with the Plan's in-network provider. The Plan denied your request. The Plan says they have multiple in-network providers available to treat your medical needs.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve office or other outpatient visit (99203) to be provided by an out-of-network (OON) provider.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for subsequent nursing facility care provided on May 27, 2021.  You asked the Plan to pay for subsequent nursing facility care. The Plan denied your request. The Plan says the Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation. During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  The enrollee ended Medicare Hospice benefits on May 22, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for subsequent nursing facility care provided on May 27, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Eylea.  You asked the Plan to pre-approve Eylea. You say that the enrollee was treated with Avastin with no improvement. The Plan denied your request. The Plan says the enrollee has not tried Lucentis.   Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  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 Eylea. Our physician reviewer found that the enrollee has a diagnosis of exudative age-related macular degeneration, left eye, with active choroidal neovascularization. The Plan requires a trial of Lucentis before they will approve the requested drug. The documentation does not support that Lucentis (Ranibizumab) has been tried and failed. The documentation does not support that Lucentis would likely be less effective, and/or would likely have adverse effects for the enrollee in this case.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Eylea have not been met. Therefore, we decided that the Plan does not have to pre-approve Eylea.