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

 We decided that the Plan does not have to pay for observation care discharge day management (99217) provided on May 10, 2021.  

You asked the Plan to pay for observation care discharge day management. You say that you would like this claim reprocessed based on the medical records provided. The Plan denied your request. The Plan says this claim was not billed in accordance with Medicare rules.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. The rules also say that when a patient is admitted for observation care and then is discharged on a different calendar date, the physician shall report Initial Observation Care, from CPT code range 99218 - 99220, and CPT observation care discharge CPT code 99217 

In this case, the CPT Code Manual definition of code 99217 is observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]).  

We looked at the file and Medicare rules. In this case, the medical documentation indicates that the enrollee entered observation care on May 9, 2021, and was discharged on May 10, 2021. There is no documentation provided that the appropriate qualifying initial observation care procedure code was billed. Without this code, the observation care discharge day management coded as 99217 is not eligible for payment. Based on this information, we decided that Medicare rules for coverage of observation care discharge day management have not been met. Therefore, we decided that the Plan does not have to pay for observation care discharge day management (99217) provided on May 10, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for the cataract surgeries provided from July 26, 2021, to August 2, 2021.  You asked the Plan to waive the copayments for the cataract surgeries. You say that the extra procedures were necessary. The Plan denied your request. The Plan says you have been asked to pay 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 a $175 copayment for an in-network ambulatory surgical center.    You have been asked to pay a $175 copayment for each of the cataract surgeries. The cataract surgeries fall within the "Outpatient surgery, including services provided at hospital outpatient facilities and ambulatory surgical centers" 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 copayments for the cataract surgeries provided from July 26, 2021, to August 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve stab phlebectomy of the accessory/tributary veins.  You asked the Plan to pre-approve the requested vascular procedures. You say that it is felt that all of the veins should be treated at once to ensure symptoms are treated. The Plan denied your request. The Plan says treatment of the tributary veins is not allowed until after saphenous reflux is treated.  The Plan follows Medicare rules. Medicare rules say that treatment of tributary veins is only covered after saphenous reflux is corrected and conservative therapy fails to help these veins.  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 vascular procedures. Our reviewer says that the requested procedures are not considered reasonable and necessary at this time. Our physician reviewer found the LCD does not provide for coverage of simultaneous ablation of the accessory saphenous vein and stab phlebectomy. The rules require that the more proximal ablation is performed first, reserving stab phlebectomy for continued symptomatic varicose veins that are greater than 4 mm in diameter and continue to symptomatic despite resolution of truncal reflux and efforts at conservative treatment for a 6-week trial following successful ablation. It should be noted that the ablation has already been approved. However, there is no documentation that the approved procedure has been performed and that the patient has continued symptoms despite this treatment. Therefore, LCD criteria are not 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 the requested vascular procedures have not been met. Therefore, we decided that the Plan does not have to pre-approve stab phlebectomy of the accessory/tributary veins.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Gel-One (J7326) to be supplied by an outside specialty pharmacy.  You asked the Plan to pre-approve Gel-One. You say that you really need this injection in both of your knees because the other injection you have been getting is not working. The Plan denied your request. The Plan says this request will not be certified as the medication will not be supplied by the provider's office and instead is supplied by an outside specialty pharmacy.  The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  In this case, we have confirmed that the requested medication will be dispensed by a pharmacy and will be brought to the office for administration. Since the medication does not represent an expense to the physician and will not be included in the physician's bill, it is not eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Gel-One (J7326) to be supplied by an outside specialty pharmacy.   Benefits for Gel-One 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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for an MRI scan of the brain (70551) provided on July 15, 2021.  You asked the Plan to waive the copayment for an MRI of the brain. You say that your doctor ordered the medical procedure at issue. The Plan denied your request. The Plan says the correct copayment was applied.  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 $150 copayment for Medicare-covered radiological diagnostic services, not including X-rays.   You have been asked to pay a $150 copayment for an MRI of the brain. An MRI of the brain falls within the "Outpatient Diagnostic Tests and Therapeutic Services and Supplies" 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 an MRI scan of the brain (70551) provided on July 15, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pathology services provided on January 18, 2021.  You asked the Plan to pay for the services provided. You say that the codes may be payable as billed. The Plan denied your request. The Plan says the code must be reported with modifier 26.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.    We looked at the file and the rules. Since this service was rendered to a hospital outpatient, only the professional component is payable. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the pathology services provided on January 18, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the placement of a breast localization device provided on June 3, 2021.  You asked the Plan to waive the copayment for the placement of the breast localization device. You say that the service was for one day and you are being charged for two visits. The Plan denied your request. The Plan says you have been asked to pay 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 a $350 copayment for in-network Medicare-covered surgery or other services provided to you at an outpatient hospital, including but not limited to hospital or other facility charges and physician or surgical charges.   You have been asked to pay a $350 copayment for the placement of the breast localization device. The placement of the breast localization device falls within the "Outpatient Surgery and Other Medical Services Provided at Hospital Outpatient Facilities and Ambulatory Surgical Centers" benefit category. The record shows two separate services were completed.  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 placement of a breast localization device provided on June 3, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on August 12, 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.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, molecular genetic screening, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on August 12, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services provided from July 20, 2021, to July 24, 2021.  You asked the Plan to pay for IRF care. You say that due to your family situation and doctor recommendation, you did the short term inpatient rehabilitation (rehab). You say that you moved 5 hours away from your home to stay with a family member to help with your long term care. The Plan denied your request. The Plan says the IRF services were 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 pay for IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the provided documentation does not indicate that you had complex nursing or rehabilitation needs. The reviewer found that there was no documentation of a need for an intensive rehabilitation program. The reviewer also found that there is not a reasonable expectation that you were able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Therefore, the reviewer found that the IRF services were 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 IRF care have not been met. Specifically, the file shows there was no documentation of a need for an intensive rehabilitation program. Therefore, we decided that the Plan does not have to pay for acute inpatient rehabilitation facility (IRF) admission and services provided from July 20, 2021, to July 24, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Lucentis for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is no record from the prescriber showing a trial of the preferred step therapy drugs.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications. 

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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found based on the medical records provided, there is no evidence of a trial and failure of the required drugs. The enrollee's medical provider noted that Avastin is on backorder. Review of the Food and Drug Administration Drug Shortages website reveals no evidence of a shortage of Avastin, Mvasi, or Zirabev. There is no evidence that these drugs would likely be less effective and/or likely to have adverse effects for the enrollee. 

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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Lucentis for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the excision services coded 15945 provided on April 7, 2021.  You asked the Plan to pay for the excision services. 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 supported by the documentation.  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 15945 is excision, ischial pressure ulcer, with skin flap closure; with ostectomy.  We find that CPT code 15945 is not supported in the medical record. Specifically, the documentation submitted did not include documentation of excision, with ostectomy; therefore, the billed service cannot be verified.   Based on this information, we decided that Medicare rules for coverage of the excision services have not been met. Therefore, we decided that the Plan does not have to pay for the excision services coded 15945 provided on April 7, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pay for additional supplies (procedure code 99072) provided to the enrollee on December 21, 2020.  You asked the Plan to pay for the supplies. You say that this should be paid for. The Plan denied your request. The Plan says CPT 99072 will be disallowed when billed in conjunction with another CPT and/or Healthcare Common Procedure Coding System (HCPCS) procedure code.  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 99072 is "Additional supplies, materials, and clinical staff time over and above those usually included in an office visit or other non-facility service(s), when performed during a Public Health Emergency, as defined by law, due to respiratory-transmitted infectious disease."  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 supplies. Our reviewer says that the supplies at issue in this case were not supported by the medical records. Our reviewer found that per the Medicare guidelines, CPT 99072 has a status indicator of "B" (There are no RVUs (relative value units) for this code; CMS considers it to be bundled with whatever service was provided that day; CMS contractors will not pay for this service. Providers may not bill the beneficiary for this service. Additionally, issuing an Advanced Beneficiary Notice (ABN/waiver) related to this service is not an option.  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 supplies have not been met. Therefore, we decided that the Plan does not have to pay for additional supplies (procedure code 99072) provided to the enrollee on December 21, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the electrocardiogram services (93010) provided on January 28, 2021.  You asked the Plan to pay for the electrocardiogram services. You say that you would like this claim reprocessed considering the supporting documentation. The Plan denied your request. The Plan says the documentation provided does not collaborate the services 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.  We looked at the file and Medicare rules. The electrocardiogram services have been billed as occurring on January 28, 2021. However, the documentation provided indicates that electrocardiogram services were performed on January 26, 2021.  There is no evidence that supports electrocardiogram services as being performed on January 28, 2021. Based on this information, we decided that Medicare rules for coverage of the electrocardiogram services have not been met. Therefore, we decided that the Plan does not have to pay for the electrocardiogram services (93010) provided on January 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for Computed Tomography (CT) of the head or brain (70450) provided on July 30, 2021.

You asked the Plan to pay for the Computed Tomography of the head or brain. You say that you would like reconsideration because the member had multiple exams on the same date of service. The Plan denied your request. The Plan says a coding edit exist between CPT code 70496 and 70450.

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 70450 is a column II code to column I code 70496. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for Computed Tomography (CT) of the head or brain (70450) provided on July 30, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for inpatient hospital services with a reported secondary diagnosis code of G93.41, provided on December 10 - December 12, 2020.  You asked the Plan to pay for the inpatient hospital services with a reported secondary diagnosis code of G93.41. You say that the records provided support payment on the claim as it was billed.  The Plan denied your request. The Plan says the documentation in the medical record was unclear regarding metabolic encephalopathy. The Plan says that, while metabolic encephalopathy was documented on discharge summary, other provider documentation was unclear regarding this condition.  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 secondary diagnosis code G93.41, defined as Metabolic encephalopathy. 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 services with a reported secondary diagnosis code of G93.41. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found review of the documentation received show it was incomplete to reflect evidence of an alteration in mental status from the patient's known baseline of Alzheimer's dementia during this encounter in order to substantiate the condition of metabolic encephalopathy. The review has determined that the documentation did not support the reporting of G93.41 as the secondary diagnosis for this hospital admission.   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 with a reported secondary diagnosis code of G93.41, provided on December 10 - December 12, 2020.