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 the services are necessary. The Plan denied your
request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 based on the medical records provided there is concern that the enrollee will not be
able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
inpatient rehabilitation facility due to her cognitive level and level of endurance. Care at the skilled nursing
facility level appears to be appropriate 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 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 4kscore testing rendered on June 7, 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 testing is not covered.
The Plan must follow Medicare rules. The rules say that 4Kscore testing is not reasonable and necessary and is not covered by Medicare. The test at issue is the 4Kscore test. This test is not covered by Medicare for any indication. Therefore, we decided that the Plan does not have to pay for the 4kscore testing rendered on June 7, 2021
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a driveline management kit (Q0508) provided on April 22,
2020, by an out-of-network provider.
You asked the Plan to pay for a driveline management kit. You say that the item at issue was a medical
necessity for the enrollee. The Plan denied your request. The Plan says rules for out-of-network care have not
been met.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for a driveline management kit (Q0508) provided on
April 22, 2020, by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
You asked the Plan to pre-approve a Vertiflex Superion spacer. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
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 a Vertiflex Superion spacer. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the vertilfex spacer remains experimental. More research is needed to show safety and efficacy. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a Vertiflex Superion spacer have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided on April 2, 2021.

You asked the Plan to pay for the subsequent hospital care services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.

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 99233 is Subsequent hospital care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Typically, 35 minutes are spent at the bedside and on the patient's hospital floor or unit. 

We find that CPT code 99233 is not supported in the medical record. Specifically, this code was billed without an appropriate primary or first-listed diagnosis. Diagnosis R65.20 (severe sepsis without shock) was billed as the primary; however, this diagnosis requires a specific code first underlying infection. Based on this information, we decided that Medicare rules for coverage of the subsequent hospital care services have not been met. Therefore, we decided that the Plan does not have to pay for the subsequent hospital care services coded 99233 provided on April 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided to the enrollee from June
10, 2019.
You asked the Plan to pay for home health services. You say that the final claim was sent on November 27,
2019. During this time, you were moving offices that caused the delay in sending. The Plan denied your
request. The Plan says a refund of the RAP payment for June 10, 2019 was requested based on failure to file a
final claim.
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, a review of
the enrollee's claim history shows that the Health Plan paid the RAP on August 8, 2019. 60 days from the paid
date of the RAP is October 7, 2019. A final claim for the home health services was not received prior to
October 8, 2019. No final claim was submitted to the Health Plan prior to the reconsideration request.
Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee
from June 10, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for wound repair (12002) provided on April 16, 2021.
You asked the Plan to pay for wound repair. You say that this is supported in the records. The Plan denied your
request. The Plan says this is not separately payable.
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 12002
is a column II code to column I code 36556. 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 wound repair (12002) provided on April 16, 2021.
Appeal type: Supplemental Benefit
Decision: Favorable

We decided that the Plan has to pay for the comprehensive oral evaluation (D0150), panoramic radiographic image (D0330), surgical removal of erupted teeth (D7210) and the unspecified adjunctive procedure (D9999) provided on November 11, 2020.
You asked the Plan to pay for the dental services. You say that you would like reconsideration because you were told by the Plan that these services would be covered if rendered by this provider. The Plan denied your request. The Plan says that you did not receive these services from a participating dental provider.
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. The Plan covers the dental services when the services are medically necessary and reasonable. We looked at your request, the file, and Medicare rules. Based on this information, we decided that the Plan's rules for coverage of the dental services have been met. Specifically, the contract with the Plan indicates that these services would be covered if rendered by a participating network provider. Though this provider is not in-network with the Plan, you state that you were referred to this provider by an agent of the Plan. The Plan does not address your argument. We requested clarification from the Plan and did not receive any evidence to show that you were not referred to this provider by an agent of the Plan. It is the burden of the Health Plan to substantiate their denial with evidence. This denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the comprehensive oral evaluation (D0150), panoramic radiographic image (D0330), surgical removal of erupted teeth (D7210) and the unspecified adjunctive procedure (D9999) provided on November 11, 2020.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.

You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.

The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found you did not require skilled therapy to establish a safe and effective maintenance program. As a practical matter, you did not require any skilled services on an inpatient basis, at a SNF level of care as of November 24, 2021. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to waive the refund request for a single "per diem" payment for the SNF services provided from November 1, 2018, through November 30, 2018, billed with Resource Utilization Group (RUG) code RUB30.

You asked the Plan to waive the refund request for a single "per diem" payment for the SNF stay. You say that the Plan is requesting recoupment for a single day during the SNF day; however, payment was never made for 30 days for this month. As such, no refund should be due. The Plan denied your request. The Plan says that the claim incorrectly billed for an additional day at the RHA rate. Only 29 days are payable.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has failed to show that the amount being requested as recoupment for this month of SNF care corresponds to the single day that was non-payable as a Leave of Absence from the facility. The remittance shows that only 29 days of SNF care were paid on April 7, 2020 (at $11,527), and that recoupment was requested in the amount of $2859.85 on January 11, 2021. The Plan's review found that the claim was billed with the correct RUG rate, but that one additional day was billed improperly (total of 30 days) due to the Leave of Absence. However, there is no evidence to justified that the difference between 29 paid days and 30 paid days would equal to the amount requested for recoupment. As such, the Plan must waive this recoupment request. Therefore, we decided that the Plan has to waive the refund request for a single "per diem" payment for the SNF services provided from November 1, 2018, through November 30, 2018, billed with Resource Utilization Group (RUG) code RUB30.

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for radiology services (76000) provided August 5, 2021.
You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The
Plan denied your request. The Plan says the code billed shares a bundled relationship with another procedure
billed and cannot be paid.
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 76000
shares a bundled relationship with code 71260. 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 radiology services (76000) provided August 5, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the problem focused limited re-evaluation (D0170) and
clinical crown lengthening (D4249) provided on November 4, 2020, and November 12, 2020.
You asked the Plan to pay for the problem focused limited re-evaluation and clinical crown lengthening. The
Plan denied your request. The Plan says these services are not covered under your plan.
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
problem focused limited re-evaluation (D0170) and clinical crown lengthening (D4249) provided on November
4, 2020, and November 12, 2020
Appeal type: Lab
Decision: Favorable

We decided that the Plan has to pay for the drug testing coded G0483 provided on June 8, 2021.
You asked the Plan to pay for the drug testing. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that medical records were not received from the provider.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Review of the file shows that the Plan states that medical records were not received from this provider. However, the case file does contain medical records from this provider for this date of service. The Plan does not give any other reason on why this claim was denied. Therefore, the Plan has not substantiated their denial. Therefore, we decided that the Plan has to pay for the drug testing coded G0483 provided on June 8, 2021.
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: 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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 there are no services at the current facility that you require that are not already available and covered at the current facility. Therefore, transfer to LTACH would not be clinically advantageous. Transfer to a lower level of care may be considered when you are more stable and 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the tube thoracostomy rendered on October 27, 2020.
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 rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well. The provider submitted a claim for procedure codes 32551 (tube thoracostomy) and 39501 (repair of laceration of diaphragm). Code 32551 is a column II code with a modifier indicator of 1 when billed with column I code
39501. Code 32551 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the tube thoracostomy rendered on October 27, 2020.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
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 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 this 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.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the established patient domiciliary or rest home visit (99336) brief emotional/behavioral assessment (96127) provided on March 6, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the domiciliary or rest home visit. You say that please review the requested medical records for payment. 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 established patient domiciliary or rest home visit (99336) brief emotional/behavioral assessment (96127) provided on March 6, 2021 by an out-of-network (OON) provider.