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

 We decided that the Plan does not have to pay for lab services provided to the enrollee on August 4, 2021 and billed under codes 88312.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  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 these services. Our reviewer says that Medicare billing criteria are not met. Our reviewer found the records showed the provider performed laboratory test for level lV gross and microscopic surgical pathology, and special stain for diagnosis of Tinea unguim (fungal infection).  The documentation includes a special stain was performed prior to a routine stain.  The documentation does not support the need in performed a special test prior to performing routine test.  Performing a Special stain prior to review of routine stain is not reasonable and necessary. Medicare billing criteria were not met.   We looked at this coder'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 pay for lab services provided to the enrollee on August 4, 2021 and billed under codes 88312.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from June 25, 2020, to July 1, 2020.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the DRG was changed from DRG 189 to DRG 191.  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 189 (PULMONARY EDEMA AND RESPIRATORY FAILURE). The plan adjusted the DRG to 191 (CHRONIC OBSTRUCTIVE PULMONARY DISEASE WITH CC. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found there was no documentation of respiratory failure. The review has determined that the records support the use of DRG 191.   We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from June 25, 2020, to July 1, 2020.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that the enrollee cannot communicate his level of pain. The Plan denied your request. The Plan says the enrollee requires higher custodial care assistance.  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 services. Our physician reviewer found that the most recent therapy documentation indicates the enrollee is at his baseline function and is receiving comfort care only. He is medically stable and does not have any complex daily wound care, parental medications or required care for a new or malfunctioning feeding tube. He does not require any skilled nursing or rehab services on a daily basis at an inpatient level of care. He does not require skilled therapy to establish a safe and effective maintenance program. Therefore, an admission to a SNF for inpatient skilled services is 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 SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the infectious agent detection (87506) provided on  May 5, 2021.  You asked the Plan to pay for code 87506. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the medical records do not support the billing of code 87506.  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 87506 is  Infectious agent detection by nucleic acid (DNA or RNA); gastrointestinal pathogen (eg, Clostridium difficile, E. coli, Salmonella, Shigella, norovirus, Giardia), includes multiplex reverse transcription, when performed, and multiplex amplified probe technique, multiple types or subtypes, 6-11 targets.  We find that CPT code 87506 is not supported in the medical record. Specifically, the record shows that this panel had more than 11 targets. Based on this information, we decided that Medicare rules for coverage of code 87506 have not been met. Therefore, we decided that the Plan does not have to pay for the infectious agent detection (87506) provided on May 5, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for therapy services provided from April 26, 2021, through April 30, 2021.  

You asked the Plan to pay for therapy services. The Plan denied your request. The Plan says Original Medicare would be responsible for payment of all Medicare covered services related or unrelated to the member's terminal condition. The Medicare hospice benefit, through fee-for-service Medicare, covers all hospice care from the effective date of election to the date of discharge or revocation.   

During the election, fee-for-service Medicare also covers attending physician services and all care unrelated to the terminal illness until the first day of the month following the month in which hospice was revoked or discharged.  

Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice services. Original Medicare is responsible for payment for services until the first day of the month after the hospice election has been revoked or terminated.  

The enrollee ended Medicare Hospice benefits on April 4, 2021. The services in question were provided before the end of that month. Therefore, we decided that the Plan does not have to pay for therapy services provided from April 26, 2021, through April 30, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic mammography provided on June 18, 2021.

You asked the Plan to waive the copayment for the diagnostic mammography. You say that you feel you should not be responsible for this cost share amount, and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a diagnostic mammography on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $75 copayment for Outpatient diagnostic tests.

We looked at the file, the Plan's contract, and Medicare rules. The file shows that you received a diagnostic mammography on June 18, 2021. You have been asked to pay a $75 copayment for the diagnostic mammography. The diagnostic mammography falls within the Outpatient diagnostic tests 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 the diagnostic mammography provided on June 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for home health aide services provided from September 14, 2020, through September 5, 2021.  You asked the Plan to pay for home health aide services. You say that this provider has been giving you excellent care. The Plan denied your request. The Plan says this service is considered Custodial Care, which is not covered under your Plan.  The Plan must follow Medicare rules. The rules say that custodial care, which does not include services from trained medical or paramedical staff, is not covered.   We looked at the file and Medicare rules. Specifically, we find that the services at issue in this case are considered custodial in nature. Therefore, we decided that the Plan does not have to pay for home health aide services provided from September 14, 2020, through September 5, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing service (G0482) rendered by the out-of-network (OON) provider on May 10, 2021.  

You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the drug testing service (G0482) rendered by the out-of-network (OON) provider on May 10, 2021.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a breast biopsy to be provided by an out-of-network (OON) provider. 

You asked the Plan to pre-approve the OON breast biopsy. You say that you need to have the requested biopsy because of calcifications on your breast. You say that you have been unable to find a network provider available for the need procedure. The Plan denied your request. The Plan says there are network providers who are able to provide the biopsy services needed.
  
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 a breast biopsy to be provided by an out-of-network (OON) provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.  You asked the Plan to pre-approve SNF services. You say that the records provided support the need for SNF care. The Plan denied your request. The Plan says the guidelines for coverage have 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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube.  The enrollee received skilled care and improved; however, his functional improvement had plateaued by January 23, 2022, and he did not require any further inpatient skilled rehabilitation services. The enrollee's function was at or near his prior level of function and he could be discharged to a lower level of care for further services. As of January 23, 2022, the enrollee could be discharged to a lower level of 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services provided to the enrollee on August 3, 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 there are no modifiers allowed with this code pair.  

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 74220 is a column II code to column I code 74230. This claim has not been billed with an appropriate modifier to bypass the edit, as there are no modifiers allowed in this case. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services provided to the enrollee on August 3, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee from July 25, 2021, to August 23, 2021 .  You asked the Plan to pay for these services. You say that these services were medically necessary. The Plan denied your request. The Plan says Medicare coverage criteria were not 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 pay for these services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found as of July 24, 2021, the enrollee did not require any skilled nursing or rehab services on a daily basis.  She was not expected to make measurable gains within a reasonable and predictable period of time or require skilled therapy to prevent deterioration with mobility or daily activities. The enrollee did not require skilled therapy to establish a safe and effective maintenance program.  The enrollee did not have any parental medications, complex wound care or nutrition given via a feeding tube.  The enrollee plateaued by July 24, 2021, and she did not require any further inpatient skilled rehab services.  The enrollee's function was at or near her new baseline level of function and she could be discharged to a lower level of care for further services.  As of July 24, 21 the enrollee's care was custodial. Medicare coverage criteria were no longer 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 these services have not been met. Therefore, we decided that the Plan does not have to pay for skilled nursing facility services provided to the enrollee from July 25, 2021, to August 23, 2021 .
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit rendered on April 14, 2021.

You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered when billed by a chiropractor.

The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation. 

The records show that the service at issue is not manual manipulation of the spine. The file shows that the chiropractor billed code 99203 (office visit). Therefore, we decided that the Plan does not have to pay for the office visit rendered on April 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for services provided to the enrollee on March 16, 2021 and billed under code 99223.  

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. 

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 these services. Our reviewer says that Medicare billing criteria are not met. Our reviewer found this code is used when the problem(s) requiring admission are of high severity.    

Typically, 70 minutes are spent at the bedside and on the enrollee's hospital floor or unit for services rendered. The Plan denied payment for the documentation not supporting the services billed. The records show the provider reported a comprehensive history, comprehensive exam, and medical decision of high complexity.  The documentation does not support the level of evaluation and management service billed. Medicare billing criteria are not met.   

We looked at this coder'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 pay for services provided to the enrollee on March 16, 2021 and billed under code 99223.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve speech therapy.

You asked the Plan to pre-approve speech therapy. 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 follows Medicare rules. Medicare rules say that patients who are motivated, moderately alert, and have some degree of deglutition and swallowing functions are appropriate candidates for dysphagia therapy. 

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 speech therapy. Our reviewer says that the services are not medically necessary. Our physician reviewer found the requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition. The records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain the enrollee's current condition or to prevent or slow further deterioration. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of speech therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve speech therapy.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the inpatient hospital services provided from September 8, 2021, to September 9, 2021.

You asked the Plan to pay for the inpatient hospital services. You say that you would like the Plan to reconsider your request. The Plan denied your request. The Plan says that the stay was appropriately downgraded from inpatient to observation.

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 downgraded this hospital stay from inpatient to observation. The Plan did not submit medical records for this hospital stay, nor did the Plan submit documentation of attempts to obtain the medical records. Without medical records, the Plan has not shown that its decision to downgrade this stay from inpatient to observation is correct or medically justified. Therefore, we decided that the Plan has to pay for the inpatient hospital services provided from September 8, 2021, to September 9, 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.