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

We decided that the Plan does not have to pay for the emergency department visit provided on March 29, 2021.
You asked the Plan to pay for the emergency department visit (99285). You say that the medical records support CPT 99285. The Plan denied your request. The Plan says the claim does not meet criteria for approval at CPT 99285 level due to not complying with the ER note
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 99285 is Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the
urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive
examination; and 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 presenting problem(s) are of high
severity and pose an immediate significant threat to life or physiologic function.
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 emergency department visit (99285). Our reviewer says
that the service does not meet criteria for billing or reimbursement consideration. Our reviewer found the
medical records provided do not include sufficient documentation to support billing CPT 99285, therefore this
procedure 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 emergency department visit (99285) have not been met. Therefore, we
decided that the Plan does not have to pay for the emergency department visit provided on March 29, 2021 at
the 99285 level.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the unlisted pelvis or hip joint procedure provided on March 3, 2021.

You asked the Plan to pay for the unlisted pelvis or hip joint procedure. 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 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, the CPT Code Manual definition of code 27299 is unlisted procedure, pelvis or hip joint.

We find that CPT code 27299 is not supported in the medical record. Specifically, there is no payment for code 27299. This code is unable to be compared with the other code billed on the claim (27385). Based on this information, we decided that Medicare rules for coverage of the unlisted pelvis or hip joint procedure have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted pelvis or hip joint procedure provided on March 3, 2021.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the acute inpatient hospital care provided from February 4, 2020, through February 10, 2020.
You asked the Plan to pay for acute inpatient hospital care. You say that the inpatient care was medically necessary. The Plan denied your request. The Plan says that based on the clinical records provided this participant's care did not meet medical necessity criteria for acute inpatient hospital level of care. In the records provided there were no contraindications documented for discharge after the first hospital day. After emergency department evaluation and appropriate consultation, the participant's ongoing care needs could have been provided on an outpatient basis.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation supports that the criteria for inpatient payment are met in this case. Our physician reviewer found that the record indicates that the enrollee was admitted from the emergency department and was in the hospital from February 4, 2020, through February 10, 2020. The record indicates that he presented upon instruction from his hematologist with anemia refractory to iron administration for further work-up. The record indicates that the enrollee was noted to have heme positive stools and between a 1.5 to 2 gram decrease in hemoglobin. The totality of the record sufficiently documents that the treating physician had a reasonable expectation of a length of stay spanning 2 or more midnights. The elements of the coverage rule are 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 acute inpatient hospital care have been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from February 4, 2020, through February 10, 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the transtelephonic rhythm strip pacemaker evaluation(s) provided on May 3, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the transtelephonic rhythm strip pacemaker evaluation(s). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.
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 transtelephonic rhythm strip pacemaker evaluation(s) provided on May 3, 2021 by an out-of-network (OON) provider
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to provide 60 additional routine transportation trips.
You asked the Plan to provide additional transportation. You say that you need more transportation to get to and from your medical appointments. The Plan denied your request. The Plan says this request exceeds the maximum number of trips provided by your supplemental transportation benefit.
Medicare does not cover transport in a vehicle that is not an ambulance. However, the Plan offers a transportation benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. The Plan covers a maximum of 60 trips per year.
We looked at your request, the records in the case file, and the rules. Based on this information, we decided
that your request exceeds the Plan's maximum benefit for coverage of routine transportation. Therefore, we
decided that the Plan does not have to provide 60 additional routine transportation trips.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for a repair of nasal stenosis procedure (30465) provided on December 17, 2020.
You asked the Plan to pay for a repair of nasal stenosis. You say that the requested care was necessary for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met because records do not support the service billed.
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 30465 is "Repair of nasal vestibular stenosis (eg, spreader grafting, lateral nasal wall reconstruction)." 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 a repair of nasal stenosis. Our reviewer says that the procedure at issue does not meet criteria for reimbursement per submitted documentation. Our reviewer found that the operative report does not document in detail the repair using spreader grafting, lateral nasal wall reconstruction. Therefore, this procedure cannot be confirmed as performed. We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a repair of nasal stenosis have not been met. Therefore, we decided that the Plan does not have to pay for a repair of nasal stenosis procedure (30465) provided on December 17, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and acellular pertussis (Tdap)
vaccine (90715) and administration (90471) provided on June 9, 2021.
You asked the Plan to pay for a Tdap vaccine and administration. You say that you doctor said you needed this.
The Plan denied your request. The Plan says coverage of this vaccine is the responsibility of your prescription
drug plan.
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide a Tdap vaccine and
administration. The Plan follows the same rules.
Records do not show that you have been injured or directly exposed to any illness related to a Tdap vaccine and
administration. Therefore, we decided that the Plan does not have to pay for a tetanus, diphtheria toxoids and
acellular pertussis (Tdap) vaccine (90715) and administration (90471) provided on June 9, 2021.
Benefits for a Tdap vaccine and administration may be available under Medicare Part D. Contact the Plan that
administers Part D benefits for further information concerning any benefits and appeal rights
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81291, 81401, 81403, 81404, 81405, 81406, 81407, 81408, 81479, and 81439 provided on September 4, 2020.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered are not a covered benefit.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. 

We find that CPT code 81291, 81401, 81403, 81404, 81405, 81406, 81407, 81408, 81479, and 81439 is not supported in the medical record. Specifically, the place of service on the CMS-1500 form line 24B must reflect the location of the enrollee when the specimen was obtained. The submitted claim form indicates the laboratory specimen was obtained in a laboratory, place of service 81; however, the submitted medical documentation and/or claim history indicates that the specimen was obtained in an office setting place of service 11.

Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Therefore, we decided that the Plan does not have to pay for the laboratory services coded 81291, 81401, 81403, 81404, 81405, 81406, 81407, 81408, 81479, and 81439 provided on September 4, 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 these services are medically necessary. The Plan denied your request. The Plan says that you can safely receive the services you need in other settings.
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. The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for intracranial bleeding, multiple fractures (orbital, rib, left forearm and left femur) after a motor vehicle accident.
Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: 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 received skilled care and improved; however, your function had plateaued by September 25, 2021 and you did not require any further inpatient skilled rehab services. Your function was at or near your prior level of function and you could be discharged to a lower level of care for further 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 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that you need supervised care. The Plan denied your request. The Plan says rules for IRF care have not been met because the requested services are not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that the complexity of your nursing, medical, and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an
intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve foot orthotics.
You asked the Plan to pre-approve foot orthotics. You say that inserts will correct your limp and cause less pain. The Plan denied your request. The Plan says this item is not a covered benefit.
Medicare rules state that supportive devices for the feet (such as orthotics) are only covered for patients with diabetic foot disease or for patients who wear a leg brace. The Plan follows these same rules. Records show that you do not suffer from diabetic foot disease and you do not wear a leg brace. Although orthotics may be appropriate for you, neither Medicare nor the Plan provides coverage of orthotics for your condition. Therefore, we decided that the Plan does not have to pre-approve foot orthotics
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve ten (10) additional ST visits.

You asked the Plan to pre-approve ten (10) additional ST visits. You say that additional ST is medically necessary. The Plan denied your request. The Plan says additional ST is not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 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 ten (10) additional ST visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional requested therapy is not generally accepted as specific and effective therapy for the enrollee's condition beyond what was approved by the health Plan. The enrollee has had prior extensive therapy and 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 enrollee and caregivers have been instructed on a home exercise program. 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 ten (10) additional ST visits have not been met. Therefore, we decided that the Plan does not have to pre-approve ten (10) additional ST visits.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the positron emission tomography (PET) provided on May 18, 2021.
You asked the Plan to pay for the positron emission tomography (PET). You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. Providers must report services with the appropriate diagnosis and service codes that report the service billed to the highest degree of specificity. The claim itself was billed with a diagnosis code of "C50.912 defined as Malignant neoplasm of unspecified site of left female breast". However, the medical records provided indicate a more specified site was the part of the body that was the area of concern. In this case, this claim cannot be paid as billed due to a generic diagnosis code and the omission of specific codes or modifiers that identify the exact part of the body requiring the image. If more areas of the body than the left breast required imaging, the claim should have reflected that with the appropriate codes being billed and submission of the appropriate medical record documentation. Based on this information, we decided that Medicare rules for coverage of the positron emission tomography (PET) have not been met. Therefore, we decided that the Plan does not have to pay for the positron emission tomography (PET) provided on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a dental visit (99204/D0160) and two tooth extractions (D7140) provided on April 29, 2021, by an out-of-network provider.

You asked the Plan to pay for the dental services. You say that these were emergency dental services to treat a severe local and systemic infection. The Plan denied your request. The Plan says out-of-network dental care is only covered in limited circumstances. The provider in this case is out-of-network, and no prior approval was requested.

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 generally does not cover out-of-network dental care, and will cover emergency dental care from an out-of-network provider only if certain criteria are met. 

Though the Plan offers a dental benefit in excess of Medicare coverage, items or services received from out-of-network providers are not covered under this benefit. You say that these services were emergent and to treat an infection, however no medical records were provided to verify this claim. In addition, there is no documentation that you tried to contact either your assigned dental provider or the dental plan's customer service prior to services or that you were reasonably unable to do so based on your condition and the circumstances at the time. Based on this information, we have decided that the Plan's rules for coverage of dental services are not met. Therefore, we decided that the Plan does not have to pay for a dental visit (99204/D0160) and two tooth extractions (D7140) provided on April 29, 2021, by an out-of-network provider.