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

We decided that the Plan does not have to pay for the laboratory services provided on May 6, 2020.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says 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.
The Plan must follow Medicare rules. Medicare rules say that payment under the Medicare Physician Fee Schedule (MPFS), the Place of Service (POS) code is generally used to reflect the actual setting where the beneficiary receives the face to-face service. t the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the laboratory services have not been met. Specifically, the claim was billed with a laboratory POS code. The record indicates that the member's face-to-face service was rendered in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 6, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the serum iron studies provided on May 13, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not
billed with an appropriate diagnosis code.
The Plan must follow Medicare rules. Medicare rules say that only certain diagnosis codes can be billed for
serum iron studies.
We looked at the file and Medicare rules. NCD 190.18 provides a list of covered diagnosis codes for serum
iron studies. The services in this case were billed with diagnosis codes G89.4, Z79.899, R53.83, and J06.9.
These codes are not listed in the NCD as covered diagnosis codes for serum iron studies. 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 the serum iron studies provided on May 13, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Percutaneous Neuromodulation Therapy (PNT).
You asked the Plan to pre-approve PNT. You say that the clinical information provided supports the need for the services in dispute. The Plan denied your request. The Plan says this is not a covered benefit for the enrollee's condition.
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 PNT. Our reviewer says that Percutaneous Neuromodulation Therapy (PNT) is not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has chronic left lower extremity pain. The enrollee has lumbar radiculopathy. She has tried Physical Therapy, Home exercise, Gabapentin, Lyrica, Cymbalta, nerve blocks and steroids. The request is for the insertion of the Sprint Percutaneous Neuromodulation therapy. The device would be considered experimental/investigational for this enrollee's condition.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of PNT have not been met. Therefore, we decided that the Plan does not have to pre-approve Percutaneous Neuromodulation Therapy (PNT).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the diagnostic colonoscopy with specimen collection (45378) provided on May 6, 2021.
You asked the Plan to waive the copayment for the diagnostic colonoscopy. You say that this was a standard colonoscopy screening and you have not had a copay for this service before. The Plan denied your request. The Plan says this claim was processed correctly, and your cost-share was assessed in accordance with your contract. 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 $175 copayment for outpatient surgery services. A diagnostic colonoscopy is performed in order to explain symptoms identified by your physician, because you've had a previous colonoscopy that resulted in the removal of polyps, or other colorectal related conditions. If your physician orders a diagnostic colonoscopy, cost-sharing will apply.
You have been asked to pay a $175 copayment for the diagnostic colonoscopy. The colonoscopy billed with code 45378 is indicated as a diagnostic colonoscopy with a collection of specimens and is classified as a surgical procedure. The record indicates that this colonoscopy was billed with a colorectal related condition, which means the service is diagnostic rather than a screening. 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 colonoscopy with specimen collection (45378) provided on May 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the rotary wing air transport ambulance service (A0431) provided on February 1, 2021.
You asked the Plan to pay for the rotary wing air transport ambulance service. You say that you contracted the Coronavirus while you were in Mexico and were taken to a hospital there. You also say that your condition was getting worse, the hospital staff was not caring for you appropriately, and your family had you transported back to the United States. The Plan denied your request. The Plan says this is not a Medicare covered service.
Medicare says that plans must pay for emergency and urgently needed services. The Plan contract says that while outside of the service area, coverage is limited to emergencies, urgently needed care, renal dialysis and pre-approved care. The rules also say that Medicare pays for air ambulance services only if your medical condition is such that transportation by ground ambulance is not appropriate. 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 rotary wing air transport ambulance service. Our reviewer says that the air transport to the hospital in Tijuana, Mexico was not supported in the documentation and will be considered not medically necessary. Our physician reviewer found the documentation does not support that your condition was such that at the time of transport, ground transport alone would have endangered your health. Our reviewer also found that there was no indication that the sending hospital was inadequate to care for you there. 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 rotary wing air transport ambulance service have not been met.
Therefore, we decided that the Plan does not have to pay for the rotary wing air transport ambulance service (A0431) provided on February 1, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99285) provided on December 28, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a duplicate
service.
The Plan must follow Medicare rules. Medicare rules say that claims or claim lines that have been determined
to be exact duplicates of another claim or claim line are denied.
We looked at the file and Medicare rules. The services in question were billed on a duplicate claim to one
previously processed and paid by the Plan. Duplicate claims are not payable. 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 the services (99285) provided on December 28, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the lab services (87506) provided on March 24, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed code is not supported.

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 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 use of code 87506 is not supported by the records provided. Our reviewer found that the documentation does not support the need for 6-11 targets per Medicare guidelines. The documented diagnosis is unspecified, diarrhea. Per Medicare rules, the limit for general inpatient coverage in immune competent beneficiaries is 5 bacterial targets. 

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 the lab services (87506) provided on March 24, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex procedure.

You asked the Plan to pre-approve the Vertiflex procedure. You say that this request is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered experimental/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 the Vertiflex procedure. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed. 

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 Vertiflex procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex procedure.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve the admission. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in long-term care with part-time skilled services.
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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found you do not require skilled nursing services with the specialized skill, knowledge and judgment of a skilled professional nurse to safely and effectively provide medically necessary and reasonable treatment in a SNF. The documentation does not reveal evidence of complex wound care, new enteral feedings, or other skilled nursing SNF need. Your functional level does not require skilled therapy services with the specialized skill, knowledge and judgment of a qualified therapist to safely and effectively provide medically necessary and reasonable treatment in a SNF. You do not require skilled nursing or skilled therapy services (or a combination of these services) on a "daily basis" in a SNF. As a practical matter, you do not require the necessary services on an inpatient basis, in a skilled nursing facility setting. 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 admission have not been met. Therefore, we decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on May 27, 2021.
You asked the Plan to pay for the office visit (99202). You say that the Plan should pay this claim. The Plan denied your request. The Plan says office visits are not covered when provided 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. Therefore, we decided that the Plan does not have to pay for the office visit provided on May 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
You asked the Plan to pay for the LTACH services. You say that this inpatient admission was medically necessary. The Plan denied your request. The Plan says the enrollee did not require extensive or complex wound care management by skilled nursing of at least six and a half hours per day.
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 pay for 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 enrollee was receiving appropriate care at the present acute care hospital. The enrollee did not require services at the LTACH that were not available at the acute care hospital where he was currently receiving 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pay for long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.
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 you are receiving acute hospital care, and acute care services have not been denied. The documentation does not support that you require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. The clinical assessment does not support that you are reasonably expected to benefit from, and improve with, LTACH 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 the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve catheter placement in coronary artery(s) for a coronary angiography.
You asked the Plan to pre-approve catheter placement in coronary artery(s) for a coronary angiography. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve catheter placement in coronary artery(s) for a coronary angiography. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided records do not support the medical necessity and reasonableness, as defined by Medicare rules, of the requested service for the enrollee's condition. The elements of the coverage criteria are not satisfied. The requested service cannot be recommended. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of catheter placement in coronary artery(s) for a coronary angiography have not
been met. Therefore, we decided that the Plan does not have to pre-approve catheter placement in coronary artery(s) for a coronary angiography.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient psychiatric care from October 13, 2021,
forward.
You asked the Plan to pre-approve inpatient psychiatric care from October 13, 2021, 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 October
13, 2021, forward. Our reviewer says that the enrollee does not meet the criteria for acute inpatient mental
health treatment from October 13, 2021, forward. Our physician reviewer found the enrollee did not require
inpatient mental health treatment from October 13, 2021, forward 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. It did not appear that the services 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 October 13, 2021, forward have not been met.
Therefore, we decided that the Plan does not have to pre-approve inpatient psychiatric care from October 13,
2021, forward.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing rendered on October 5, 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 were billed incorrectly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an office setting and should have been billed with POS code 11. Therefore, we decided that the Plan does not have to pay for the drug testing rendered on October 5, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bone marrow aspiration.
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 the clinical value and effectiveness of bone marrow aspirate in the setting of spinal fusion surgery has not been demonstrated in the peer-reviewed literature.
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. Detailed documentation is not evident regarding a specific indication to support the request for bone marrow aspirate for the approved surgery. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of bone marrow aspirate for your medical condition. There is no compelling rationale presented or
extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Our physician reviewer found that your 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 bone marrow aspiration.