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

 We decided that the Plan does not have to pre-approve inpatient psychiatric care from February 23, 2022, forward.  You asked the Plan to pre-approve inpatient psychiatric care from February 23, 2022, forward. You say that the services at issue are medically necessary. The Plan denied your request. The Plan says the services at issue are not medically necessary.  The Plan must follow Medicare rules. The rules say that inpatient psychiatric services may be covered if the patient requires active treatment.   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 inpatient psychiatric care from February 23, 2022, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental health treatment beyond the date in question of February 23, 2022, forward. Our physician reviewer found the enrollee did not require inpatient mental health treatment beyond February 23, 2022, as he was not a danger to himself or others and did not have any delusions, auditory or visual hallucinations. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve the enrollee's condition or for the purpose of diagnosis.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of inpatient psychiatric care from February 23, 2022, forward have not been met. Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from February 23, 2022, forward.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that this service is considered experimental and investigational.  The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The vertiflex device is experimental. More research is needed. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.       We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve medial branch blocks.  You asked the Plan to pre-approve the requested services. The Plan denied your request. The Plan says the enrollee does not have localized pain.  The Plan follows Medicare rules. Medicare rules say that facet joint interventions are 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 the enrollee has chronic low back pain. She had a sacroiliac joint injection which produced 100% pain relief for a month. She has a spinal cord stimulator but needs a generator change.  She takes Tylenol, Tramadol, Voltaren gel, and medical marijuana for pain. She has tried physical and occupational therapy, and acupuncture. On physical exam, tenderness is noted over several facet joints. However, facet loading tests, range of motion limitations and imaging are not documented. At this point, the request does not meet the documentation requirements for coverage. Therefore, the request is deemed 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 requested services have not been met. Therefore, we decided that the Plan does not have to pre-approve medial branch blocks.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on October 25, 2021.  You asked the Plan to pay for a diagnostic or therapeutic injection. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.    The Plan must follow Medicare rules. Medicare rules say that 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 a diagnostic or therapeutic injection have not been met. Specifically, the case record does not contain documentation to support the medical necessity of the services at issue. Therefore, we decided that the Plan does not have to pay for a diagnostic or therapeutic injection (62320) provided on October 25, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the knee orthotic (L1851) and suspension sleeves (L2397, provided on October 6, 2021.  You asked the Plan to pay for the knee orthotic and suspension sleeves. You say that the items are medically necessary. The Plan denied your request. The Plan says the documentation submitted doesn't provide any objective examination to show any  instability, ligamental laxity or deformity.  The Plan must follow Medicare rules. Medicare rules say that claims for L1832, L1833, L1843, L1845, L1850, L1851 or L1852 will be denied as not reasonable and necessary when the beneficiary does not meet the criteria for coverage.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the knee orthotic and suspension sleeves have not been met. Therefore, we decided that the Plan does not have to pay for the knee orthotic (L1851) and suspension sleeves (L2397, provided on October 6, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for the injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (CPT code 64495) provided to the enrollee on August 11, 2021.  You asked the Plan to pay for the service. You say that the service was medically necessary. The Plan denied your request. The Plan says that there was no quantified estimation of benefit from prior injections. The Plan states there was no described dermatone or radicular pain pattern, there was no documented trial of activity modification, home exercises, non-steroidal anti-inflammatory drugs (NSAIDs), physical therapy and spine manipulation for six (6) weeks or longer. The Plan states there is no significant decrease in range of motion, strength, or stability sufficient to interfere with activities of daily living (ADLs) or having significant impact on school or job performance. The Plan states there was no documented comprehensive treatment plan with milestones and goals outline. The Plan states there was no documented absence of other serious pathology, i.e, acute fracture, dislocation, ligament rupture, tumor, arthritis, or infection.  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 service. Our physician reviewer found the enrollee meets all of the LCD criteria. The procedure was medically reasonable and 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 service have been met. Therefore, we decided that the Plan has to pay for the injection(s), diagnostic or therapeutic agent, paravertebral facet (zygapophyseal) joint (or nerves innervating that joint) with image guidance (fluoroscopy or CT), lumbar or sacral; third and any additional level(s) (CPT code 64495) provided to the enrollee on August 11, 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated (CPT code 49507 RT and LT) provided on December 2, 2020.  You asked the Plan to pay for the services. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not covered 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 services have not been met. CPT 49507- RT and 49507-LT has an MUE value of 1 but billed 2 units. Per the above guidelines, we find the Medicare rule for payment of this date of service December 02, 2020, claim has not been met. If the provider determines that a billing error occurred during the initial submission of the denied claim, the plan will accept a submission of a corrected claim to consider services for payment. Therefore, we decided that the Plan does not have to pay for the repair initial inguinal hernia, age 5 years or older; incarcerated or strangulated (CPT code 49507 RT and LT) provided on December 2, 2020.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided on March 25, 2021.  You asked the Plan to pay for the drug testing. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not supported by the records.  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 drug testing have not been met. CPT ode G0483 (1 Unit) remains not supported. The place of service on the CMS-1500 form line 24B must reflect the location of the patient when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, POS 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting POS 11. Also, the laboratory results submitted indicate the specimen was collected on March 25, 2021, and received by the lab on March 29, 2021; therefore, the billed code cannot be verified. It is noted multiple attempts were made to obtain additional information from the provider. Therefore, we decided that the Plan does not have to pay for the drug testing (CPT code G0483) provided on March 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on September 17, 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 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 September 17, 2020.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Freestle Libre sensor.

You asked the Plan to pre-approve the Freestle Libre sensor. You say that the item is medically necessary. The Plan denied your request. The Plan says the member is not adjusting their insulin doses based on their blood glucose readings.

The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.

We looked at the file and Medicare rules. The documentation indicates that the enrollee does not require frequent self-adjustment of insulin dosage based on the blood glucose testing results. Based on this information, we decided that Medicare rules for coverage of the Freestle Libre sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve the Freestle Libre sensor.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from July 15, 2021, to July 18, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that you feel the stay should be covered in full. The Plan denied your request. The Plan says you have been charged the correct cost sharing 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 $275 per day for days 1-7 and $0 per day for days 8-90 for each inpatient stay.   The file shows that you were in the hospital from July 15, 2021, to July 18, 2021, but there is no copayment for the discharge date.  Therefore, you have been asked to pay $275 per day for the first 3 days of inpatient hospital services. The total for your stay is $825 ($275 copayment x 3 days = $825). The inpatient hospital services fall 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 inpatient hospital services provided from July 15, 2021, to July 18, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90832) provided on September 9, 2021.  You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90832) provided on September 9, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for ambulance services you received on May 17, 2021.  

You asked the Plan to waive the copayment for the ambulance services. You say that you were told when you were discharged that this was a courtesy service for you.  You said that had you known there would be a charge, you would have taken a cab. The Plan denied your request. The Plan says you were charged this copayment correctly. 

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 $50 copayment for ambulance services.   

You have been asked to pay a $50 copayment for the ambulance services. This cost sharing applies regardless of the reason for the transport. 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 ambulance services you received on May 17, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a total electric hospital bed (E0266), delivery and set up (A9901), and sales tax (S9999), provided on August 16, 2021.  You asked the Plan to pay for a total electric hospital bed, delivery and set up, and sales tax. You say that the services should be covered. The Plan denied your request. The Plan says these are not covered services.  The Plan must follow Medicare rules. Medicare rules say that a total electric hospital bed is not covered.   While a total electric hospital bed may be appropriate in this case, neither the Plan nor Medicare offers coverage for this item. Therefore, we decided that the Plan does not have to pay for a total electric hospital bed (E0266), delivery and set up (A9901), and sales tax (S9999), provided on August 16, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for psychotherapy services (90853) provided on January 20, 2021.  You asked the Plan to pay for psychotherapy services. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.  The Plan must follow Medicare rules. Medicare rules say that the CP will attempt to consult with the enrollee's attending or primary care physician.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of psychotherapy services have not been met. Specifically, the provided records do not document an attempt to consult with, nor a referral from, the enrollee's attending or primary care physician. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90853) provided on January 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the deductible for outpatient hospital clinic visit you received on March 25, 2021.  You asked the Plan to waive the deductible for the outpatient hospital clinic visit. You say that you feel as though the Plan's charging of the deductible is misleading. The Plan denied your request. The Plan says you had not met your deductible at the time of these services.  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 $800 deductible which applies to outpatient hospital clinic services.       The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $800 deductible which applies to outpatient hospital clinic services. The services you received were billed as outpatient hospital clinic services, not as physician services or an office visit. This cost sharing is a contractual obligation that had not been met at the time the outpatient hospital clinic visit was received on March 25, 2021. Therefore, we decided that the Plan does not have to waive the deductible for outpatient hospital clinic visit you received on March 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from April 10, 2021, through April 13, 2021, billed with principal diagnosis code A41.9.  You asked the Plan to pay for the inpatient hospital care as billed.. You say that the documentation supports the principal diagnosis code A41.9. The Plan denied your request. The Plan says the documentation does not support the inpatient hospital care as billed.  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 principal diagnosis code, A41.9, defined as defined as sepsis unspecified organism. 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 as billed. Our reviewer says that the documentation does not support the inpatient hospital care as billed. Our physician reviewer found the review indicates that the documentation supported an admission for acute cystitis without hematuria. This patient had a history of end stage renal disease on hemodialysis (HD) and presented to the hospital with weakness and inability to ambulate. She was scheduled to have HD the day of admission but felt too weak to go. The patient was stated to be admitted for sepsis 2/2 urinary tract injection and started on intravenous antibiotics. There was no documentation of tachypnea, increased work of breathing, or abnormal blood gases as evidence to support respiratory decompensation. While sepsis was documented in the medical record as appeal correspondence has noted, a diagnosis of sepsis could not be validated from the clinical information. The review has determined that the documentation did not support the billed principal diagnosis code of A41.9 defined as sepsis, unspecified organism   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 care provided from April 10, 2021, through April 13, 2021, billed with principal diagnosis code A41.9.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for cystourethroscopy (52310) provided on September 21, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the surgical procedure. You say that the medical records provided will show proof of medical necessity. 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 cystourethroscopy (52310) provided on September 21, 2021 by an out-of-network (OON) provider.