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

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 24, 2201, to September 26, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that the services were medically necessary. The Plan denied your request. The Plan says the enrollee could have been treated at a lower level of care.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the provided documentation indicates that on admission, the enrollee's symptoms were resolving, and potassium level was resolving without expectation that they would require hospital services that would likely cross 2 midnights. Therefore, the reviewer found that the inpatient care was not 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 acute inpatient hospital care have not been met. Specifically, the file shows that the enrollee was not expected to require hospital services that would likely cross 2 midnights. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from September 24, 2201, to September 26, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the left shoulder joint.  You asked the Plan to pre-approve the shoulder MRI. You say that this imaging is needed to assess for the cause of the enrollee's shoulder pain. The Plan denied your request. The Plan says the records do not include a plain film x-ray of the shoulder joint. This is required before advanced imaging can be approved.  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 shoulder MRI. Our reviewer says that the requested imaging is not considered medically reasonable and necessary in this case. Our physician reviewer found this 69-year-old male was being treated for pain of the left shoulder joint. He presented with left shoulder pain that worsens with activity but can be unprovoked as well. It awakens him from his sleep several times throughout the night. Exam reveals limited range of motion secondary to pain in the left upper extremity. Motor strength and tone are abnormal in the left upper extremity due to pain. He has trialed ibuprofen for 4 weeks and physical therapy for 3 weeks with limited noted benefit.  However, detailed documentation is not evident regarding an x-ray of the left shoulder having been performed, with results documented. Peer-reviewed literature supports the use of MRI for shoulder pathology after a non-diagnostic radiograph (x-ray). This is not evident in this clinical scenario.  Additionally, conservative measures have only been tried for 3-4 weeks. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception. Therefore, the request for MRI of the left shoulder 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 shoulder MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI) of the left shoulder joint.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (34713) provided on July 20, 2021.  You asked the Plan to pay for the percutaneous access and closure of femoral artery for delivery of endograft through a large sheath. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the procedure code 34713 has an MUE value of 1, you billed 1 unit of 34713-RT and 34713-59-LT.  The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2.   In this case, the MUE for CPT code 34713 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the percutaneous access and closure of femoral artery for delivery of endograft through a large sheath have not been met. Therefore, we decided that the Plan does not have to pay for the percutaneous access and closure of femoral artery for delivery of endograft through a large sheath (34713) provided on July 20, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).  You asked the Plan to pay for a pneumatic compression device and garment. You say that you disagree with the denial and ask for review of the enclosed documentation supporting medical necessity of the prescribed Flexitouch PCD. The Plan denied your request. The Plan says the enrollee does not meet the LCD criteria for an advanced lymphedema pump as there is no failed four-week trial of a basic pneumatic compression device of either E0650 or E0651.  The Plan follows Medicare rules. The rules state that a PCD coded as E0652 is covered for the treatment of lymphedema extending onto the chest, trunk and/or abdomen after a four-week trial of conservative therapy demonstrating failed response to treatment with an E0650 or E0651. At least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 is required.  We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, the record does not show that the enrollee had at least four weeks of regular, daily, multiple-hour home usage of the E0650 or E0651 after careful, in-person fitting, training and supervision by a technician who is skilled in and who regularly and successfully uses the appliance provided. Therefore, we decided that the Plan does not have to pay for a pneumatic compression device (E0652) and segmental pneumatic appliance (E0667).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the injection services (62320).  You asked the Plan to pre-approve the injection services. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says despite multiple outreach attempts, no medical records were provided to support the necessity of the requested procedure.  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, despite multiple attempts by the Plan requesting medical records, no information regarding the medical necessity of the requested procedures was returned.   Without this information, the requested procedure cannot be evaluated for coverage. Based on this information, we decided that Medicare rules for coverage of the injection services have not been met. Therefore, we decided that the Plan does not have to pre-approve the injection services (62320).
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 inpatient rehab. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The necessary services can safely be provided in an alternate 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 that 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 the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on January 15, 2021 by a non-network provider.  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 rendered by a non-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 requested provider in this case is not a network provider with the Plan. The referring provider 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 laboratory services provided on January 15, 2021 by a non-network provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the trimming of dystrophic nails (G0127) provided on May 25, 2021.  You asked the Plan to pay for the trimming of dystrophic nails. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says and edit exists between CPT codes G0127 and 11721.  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 G0127 is a column II code to column I code 11721. These codes have a modifier indicator of 0, meaning that a modifier may not be used to bypass the edit. Therefore, we decided that the Plan does not have to pay for the trimming of dystrophic nails (G0127) provided on May 25, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 21, 2021 to July 1, 2021.  You asked the Plan to pay for home health services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says a RAP was not submitted within the 5 day allowable time frame.  The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  We looked at the claim submitted, the file and the Medicare rules. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Specifically, the record indicates that the RAP for these services was not submitted within 5 calendar days after the "from" date. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from June 21, 2021 to July 1, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an inpatient rehabilitation stay provided from March 13, 2021, to March 23, 2021.  You asked the Plan to waive the copayment for an inpatient rehabilitation stay. You say that you were transferred to inpatient rehabilitation and do not understand why the stay is not being covered. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct amount.  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 $325 copayment for days 1-7, each time you are admitted, for inpatient hospital care.   You had an inpatient rehabilitation stay from March 13, 2021, to March 23, 2021. This is considered a new inpatient hospital admission. Therefore, you are responsible to pay $515, which is less than the total copayment amount.   You have been asked to pay $515 for an inpatient rehabilitation stay. An inpatient rehabilitation stay falls within the inpatient hospital care benefit category. This means that you have been asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for an inpatient rehabilitation stay provided from March 13, 2021, to March 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pain management services provided on August 16, 2021.  You asked the Plan to pay for the pain management services. 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.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.    We looked at the file and Medicare rules. In this case, there were no medical records provided for review to determine if Medicare criteria have been met. Therefore, we decided that the Plan does not have to pay for the pain management services provided on August 16, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (52354, 52344) provided on May 10, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are bundled.

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 codes 52354 and 52344 are column II codes to column I code 52355. 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 services (52354, 52344) provided on May 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the genetic testing provided on April 23, 2021.  You asked the Plan to pay for the testing. The Plan denied your request. The Plan says the services were billed incorrectly.  The Plan must follow Medicare rules. Medicare rules say that if one laboratory procedure evaluates multiple genes using a next generation sequencing procedure, the laboratory shall report only one unit of service of one genomic sequencing procedure, molecular multianalyte assay, multianalyte assay with algorithmic analysis, or proprietary laboratory analysis CPT code.   We looked at the file and Medicare rules. In this case, the requested genetic testing was billed with multiple codes. Per Medicare rules, the testing should be reported with one unit of one CPT code. Based on this information, we decided that Medicare rules for coverage of the testing have not been met. Therefore, we decided that the Plan does not have to pay for the genetic testing provided on April 23, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the telephone evaluation and management
service (99442) provided on September 7, 2021.

You asked the Plan to waive the copayment. You say that you are requesting a reconsideration of the Plan's
denial for payment. The Plan denied your request. The Plan says the copayment has been applied correctly to
the service provided.

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 $10
copayment for telephonic and web-based medical consultation, diagnosis, and/or treatment of urgent
conditions.

You have been asked to pay a $10 copayment for the telehealth visit provided. This means that you have been
asked to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual
obligation you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have
to waive the copayment for the telephone evaluation and management service (99442) provided on
September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services provided on October 19, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the OON anesthesia services. You say that you are a mobile anesthesia provider and rely on the surgeon to obtain authorization. The Plan denied your request. The Plan says the services were ordered by a noncontract provider and no authorization was obtained. As such, the OON anesthesia services are also noncovered.  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 anesthesia services provided on October 19, 2021, by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital care provided July 6, 2020 to July 11, 2020.  You asked the Plan to pay for the inpatient hospital care. You say that the services were billed correctly. The Plan denied your request. The Plan says the records provided support DRG 193, not 871.  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. 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 hospital care. Our reviewer says that DRG 871 is not supported in the records. Our physician reviewer found the medical records do not support the condition treated as consistent with a systemic infectious process.   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 care provided July 6, 2020 to July 11, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the injection of therapeutic or diagnostic substances (62320) provided on September 6, 2021.  You asked the Plan to pay for the injection. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says no clinical information has been submitted to validate the medical necessity of this service.  The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, 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. Based on this information, we decided that Medicare rules for coverage of the injection have not been met. Specifically, the documentation submitted does not include any medical records. There is insufficient information to determine if Medicare criteria for coverage have been met. Therefore, we decided that the Plan does not have to pay for the injection of therapeutic or diagnostic substances (62320) provided on September 6, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve genicular radiofrequency ablation (64624).  You asked the Plan to pre-approve the procedure. You say that the enrollee has had these in the past with success. This is the safest and most effective plan to treat her pain. The Plan denied your request. The Plan says this service is considered experimental and/or unproven as there is not enough medical proof that shows the safety and or success of this treatment.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve genicular radiofrequency ablation (64624).