Persius/hicric huggingface dataset:
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the total thyroid lobectomy (60220) provided on March 31, 2021.  You asked the Plan to pay for the thyroid lobectomy. You say that the enrollee did not have the opportunity to choose a participating provider, and these services were medically necessary. The Plan denied your request. The Plan says the rendering provider listed on this claim is listed as a registered nurse assistant. The provider type of registered nurse is not allowed for payment.  The Plan follows Medicare rules. The rules say that Medicare only pays for assistant surgery services when the procedure is covered for an assistant and the person who assists the surgery bears the designation of a physician, PA, NP, or CNS.  In this case, the record does not show that the provider of the surgical assistant service is a physician, PA, NP, or CNS. Medicare only makes payment for surgical assistant services when provided by one of these types of practitioners. Therefore, we decided that the Plan does not have to pay for the total thyroid lobectomy (60220) provided on March 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.  You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says skilled therapies at home or a skilled nursing facility may be approved upon request.  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 altered mental status. 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 medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for continued inpatient hospital services from June 19, 2021, to June 28, 2021.  You asked the Plan to pay for continued inpatient care. You say that these services were medically necessary and required acute inpatient admission. The enrollee was discharged to her nursing home once her mental status was back to baseline and her condition had stabilized. The Plan denied your request. The Plan says the inpatient hospital stay was not medically necessary after June 18, 2021. The enrollee could have been treated with care directed at making them comfortable (palliative care) in a lower level of care.  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 pay for continued inpatient care. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that as of June 18, 2021, the enrollee still demonstrated some evidence of encephalopathy, but she was hemodynamically stable and was tolerating tube feedings. The review indicates that as of June 18, 2021, the enrollee no longer required services at the inpatient level of care. She required no inpatient evaluation or any therapeutic interventions. The inpatient hospital services beyond the date of June 18, 2021, were not medically necessary or indicated 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 continued inpatient care have not been met. Therefore, we decided that the Plan does not have to pay for continued inpatient hospital services from June 19, 2021, to June 28, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve OneTouch Verio Test Strips.  You asked the Plan to pre-approve OneTouch Verio Test Strips. You say that this brand of test strips is necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested test strips are not the Plan's preferred brand.  The Plan follows Medicare rules. Medicare rules say that the Plan may specific certain preferred brands provided the criteria listed in the Medicare rules section are met.  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 OneTouch Verio Test Strips. Our reviewer says that the requested test strips are not medically reasonable and necessary over the Plan's preferred brand. Our physician reviewer found there is no reason given why the OneTouch Verio brand is needed rather than the Plan's preferred brand. Therefore, the medical necessity of the requested test strips has not been met.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of OneTouch Verio Test Strips have not been met. Therefore, we decided that the Plan does not have to pre-approve OneTouch Verio Test Strips.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to a long-term acute care hospital (LTACH) for the enrollee.  You asked the Plan to pre-approve the LTACH services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee is receiving appropriate in-patient acute care and does not require transfer to a Long-Term Acute Care Hospital (LTACH).  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 that in this case, the enrollee was admitted for evaluation of choking and found to have aspiration pneumonia complicating her chronic respiratory failure. The record indicates that the enrollee requires acute care services. The enrollee continues to receive acute care services and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied.  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 admission to a long-term acute care hospital (LTACH) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital services rendered from July 23, 2020 to July 29, 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 DRG is not supported. 

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes.    

In this case, you billed the inpatient services provided with DRG 308 (cardiac arrhythmia and conduction disorders with major complication or comorbidity [MCC]) and secondary diagnosis N17.0 (acute kidney failure with tubular necrosis). 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 these services. Our reviewer says that the submitted records do not support the billing of DRG 308 and secondary diagnosis N17.0. Our physician reviewer found the records support an admission for atrial fibrillation. The documentation is unclear regarding a diagnosis of acute tubular necrosis (ATN). Although ATN was documented as a possible diagnosis by nephrology, this diagnosis was not confirmed in the record. There was no presence of non-hyline cast, urinary sodium greater than 40 mEq/L, or renal biopsy confirmation to support ATN. The DRG and secondary diagnosis are therefore not supported.   

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services rendered from July 23, 2020 to July 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for surgical assistant services for stereotactic computer assisted navigation (SCAN) procedures on the skull, meninges, and brain (61781) provided June 8, 2021.  You asked the Plan to pay for the surgical procedure. You say that the medical notes will justify the need for the assistant surgeon. The Plan denied your request. The Plan says the documentation does not clearly indicate the medical necessity of assistant surgeon for sterotactic computer assisted procedure code 61781.  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 61781 is stereotactic computer assisted navigation (SCAN) procedures on the skull, meninges, and brain.   We asked our coder 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 surgical procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our reviewer found the enrollee underwent craniotomy surgery. The Plan approved surgical assistant services for the surgery itself, this would cover the entire procedure and associated imaging. A separate code for SCAN procedures is not supported in the documentation, and therefore, will be considered not medically necessary.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pay for surgical assistant services for stereotactic computer assisted navigation (SCAN) procedures on the skull, meninges, and brain (61781) provided June 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an additional unit of procedure code 99214 provided to the enrollee on March 26, 2021.  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 submitted documentation supports one unit of CPT 99214, which was previously approved and 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, the CPT Code Manual definition of code 99214 is "Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter."  We asked our coder 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 reviewer found the medical records provided does not include sufficient documentation to validate that an office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using time for code selection, 30-39 minutes of total time is spent on the date of the encounter was performed on March 26, 2021, therefore this service cannot be verified. We looked at this coder's review, the file, and Medicare rules. 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 an additional unit of procedure code 99214 provided to the enrollee on March 26, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.  

You asked the Plan to pre-approve SNF care. You say that you have trouble breathing and walking along with stage four cancer. The Plan denied your request. The Plan says that that your record does not show that you require daily skilled nursing or skilled therapy in a SNF setting.  

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 SNF care is medically reasonable and necessary. You do not have documented skilled nursing needs. You do have documented skilled therapy needs. You are functioning below your baseline. You have not yet been shown to have reached a new plateau in function. You would benefit from strength training, compensatory strategies teaching, caregiver training and durable medical equipment evaluations. Daily skilled services are required to establish a maintenance program or to prevent deterioration of your condition. Our physician reviewer found that your condition meets Medicare criteria for SNF care.  

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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.  

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 waive or reduce the $920 copayment charged for skilled nursing
facility services provided from January 7, 2021, to January 31, 2021.

You asked the Plan to waive or reduce this copayment. You say that you do not believe this copayment is
correct. The Plan denied your request. The Plan says this copayment was charged based on the claim submitted
by the provider and the Plan contract agreement. Maximus partially reduced the copayment stating you cannot
be charged for the day of discharge. The Plan requested a reopen and provided additional information. The Plan
says that the records show you were not charged for the day of discharge. A review of the claim history shows
you were discharged on February 02, 2021 and you were not charged for that day.

The Plan is correct in this case. 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 $184 per day for days 21 to 57 of a skilled nursing facility stay.

The records show you were not charged for the day of discharge and the $920 copayment was properly applied.
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 or reduce the $920 copayment charged for skilled nursing facility
services provided from January 7, 2021 to January 31, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the expandable controller (E2377), harness (E2313), and electronic connection (E2311).  You asked the Plan to pre-approve the expandable controller, harness, and electronic connection. You say that the items are medically necessary. The Plan denied your request. The Plan says the items are not medically necessary.  The Plan follows Medicare rules. Medicare rules say that items that are not medically necessary or reasonable 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 the expandable controller, harness, and electronic connection. Our reviewer says that the items are not medically necessary. Our physician reviewer found there is no medical need to control the power options through a joystick.  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 expandable controller, harnesses, and electronic connection have not been met. Therefore, we decided that the Plan does not have to pre-approve the expandable controller (E2377), harness (E2313), and electronic connection (E2311).
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve psychotherapy services to be provided by an out-of-network provider.  

You asked the Plan to pre-approve psychotherapy services. You say that the requested psychotherapy services are a medical necessity for you. 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 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 psychotherapy services to be provided by an out-of-network provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the complete lower denture (D5120) provided on January 18, 2021.  You asked the Plan to pay for the dental item. You say that this should be covered. The Plan denied your request. The Plan says the complete upper denture is not listed as a covered service.  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 complete lower denture is not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the complete lower denture (D5120) provided on January 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve pathology examination of tissue using a microscope, intermediate complexity (CPT code 88305) provided to the enrollee on March 15, 2021.  

You asked the Plan to pre-approve the service. You say that the coding is in accordance with the correct coding guidelines, and it is your position that these codes may be payable as coded and billed by your office. The Plan denied your request. The Plan says the service is not covered as billed.  

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Per the 2021 National Physician Fee Schedule Relative Value File January Release CPT code 88305 Modifier field entry is depicted with a Blank, TC and 26 and the PCTC Indicator field is entered with a 1. In the Medicare Claims Processing Manual Chapter 23 - Fee Schedule Administration and Coding Requirements, Section 50.6 - Physician Fee Schedule Payment Policy Indicator File Record Layout, when the CPT code is billed without a modifier (a blank) this denotes the global service. As this service was billed and paid on a hospital claim per guidelines A/B MACs (B) may not pay for the technical component of radiology and other diagnostic services furnished to hospital outpatients as this is paid under the Outpatient Prospective Payment System OPPS to the hospital. Therefore, we find the Medicare rule for payment of the billed global service CPT code 88305, for March 15, 2021, has not been met. Therefore, we decided that the Plan does not have to pre-approve pathology examination of tissue using a microscope, intermediate complexity (CPT code 88305) provided to the enrollee on March 15, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a below the knee, endoskeleton, alignable system addition (L5910).  You asked the Plan to pre-approve a below the knee, endoskeleton, alignable system addition. You say that the item is medically necessary. The Plan denied your request. The Plan says the item is not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.    We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a below the knee, endoskeleton, alignable system addition have not been met. Specifically, records indicate you have a preparatory prosthesis which is a non-alignable system and the requested item is an addition for an alignable system. Therefore, we decided that the Plan does not have to pre-approve a below the knee, endoskeleton, alignable system addition (L5910).