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

 We decided that the Plan does not have to pre-approve positive emission tomography (PET) of the brain.  You asked the Plan to pre-approve the PET scan. You say that the requested scan is medically necessary for your medical condition. The Plan denied your request. The Plan says the enrollee's clinical scenario does not meet the guidance for coverage.  The Plan must follow Medicare rules. Medicare rules say that PET scans are covered only when they are medically necessary.   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 PET scan. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the enrollee is noted to have a cognitive impairment. However, the records provided for review did not support that the enrollee met diagnostic criteria for both AD and FTD, and that the requested study is being used to differentiate between the two conditions. The requested service is not considered to be reasonable and necessary in this case.  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 PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve positive emission tomography (PET) of the brain.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services received on September 13, 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 the provider did not bill as required by Medicare coding regulations.  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 71045 is a column II code to column I code 71046. 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 imaging services received on September 13, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for radiologic examination, shoulder (73030) provided August 24, 2021.  You asked the Plan to pay for the diagnostic service. You say that you are submitting medical records to support medical necessity. Please review and process your claim for payment. The Plan denied your request. The Plan says the explanation of benefits from the primary insurance carrier is needed before this claim can be considered.  The Plan must follow Medicare rules. The rules state that Medicare plans are considered secondary insurers when an enrollee has another type of insurance. This means that the Plan is not responsible for paying for services until the claim for those services has gone to the primary insurer. However, plans are still required to coordinate their benefits with the primary insurers. Plans can coordinate their benefits with the primary insurers in three ways. First, the Plan can send the bill directly to the primary insurer for payment. Second, the Plan can direct the provider to send the bill to the primary insurer. Third, the Plan can pay for the services and submit a bill for reimbursement to the primary insurer.  The Plan has met its obligation with regards to coordination of benefits. Specifically, records indicate that the primary insurance coverage show with an effective date as 03/01/2019. The Plan is secondary. As the secondary insurer, the Plan cannot be held responsible for the diagnostic service until the primary insurer has denied the claim for these services. Therefore, we decided that the Plan does not have to pay for radiologic examination, shoulder (73030) provided August 24, 2021.
Appeal type: Testing
Decision: Favorable

 We decided that the Plan has to pay for the abdominal aorta ultrasound (75706) provided on September 27, 2021.  You asked the Plan to pay for the abdominal aorta ultrasound. You say that your primary care physician referred you for this procedure, and it was approved. You also say that you need this test on a yearly basis because the doctor pointed out possible life-threatening future problems with your abdominal aorta. The Plan denied your request. The Plan says that referral or approval does not guarantee payment for this service.  Medicare rules say that a contract provider is an agent of the plan. Services and referrals given by a contract provider are considered approved by the plan unless notice is provided that the services will not be covered. The Plan follows these rules.  You were referred for the abdominal aorta ultrasound by a contract provider. The file does not show that the Plan provided notice that the abdominal aorta ultrasound would not be covered. While it does appear that this service was billed in the past, no payment was made per the documentation provided by the Plan. Since this service is covered once per lifetime, if the previous test was not paid for, the denial for this current screening is not supported. Under Medicare rules, this means the abdominal aorta ultrasound is considered approved by the Plan. Therefore, we decided that the Plan has to pay for the abdominal aorta ultrasound (75706) provided on September 27, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from
February 19, 2021, to February 21, 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 the DRG for this inpatient admission was reassigned.

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 177 (Respiratory infections and
inflammations with MCC). 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 the clinical documentation did not support that the following diagnosis impacted this hospital
admission--J96.01 Acute respiratory failure with hypoxia. The review has determined that DRG 179 is more
appropriate.

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 February 19, 2021, to February 21, 2021.
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 the enrollee still requires ongoing acute care services to complete his hospital course and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.  

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: 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 the enrollee continues to require increased oxygen support and has not completed his hospital course. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he is not currently receiving but that would be available at the LTACH facility.    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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the x-ray of the hip (73502) provided on September 20, 2021.  

You asked the Plan to pay for the x-ray of the hip. You say that you would like this claim paid for these services rendered. The Plan denied your request. The Plan says there is no documentation that supports payment for an additional service.    

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 payment for an additional unit of CPT code 73502 is not supported in the medical record. In this case, the Plan has paid for one unit of 73502. The records submitted do not indicate an additional procedure beyond what was paid. Based on this information, we decided that Medicare rules for coverage of the x-ray of the hip have not been met. Therefore, we decided that the Plan does not have to pay for the x-ray of the hip (73502) provided on September 20, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ConfirmMDx testing rendered on August 5, 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 must follow Medicare rules. The rules say that ConfirmMDx testing is covered for males with previous negative prostate biopsy who are being considered for repeat biopsy.   We looked at the file and Medicare rules. The file does not contain documentation of a prior prostate biopsy. 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 the ConfirmMDx testing rendered on August 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional physical therapy (PT) visits (97139).  

You asked the Plan to pre-approve the additional PT visits. You say that you need additional therapy due to not being quite at full motion. You also say that you recently started the strengthening and have not received your full strength back yet. The Plan denied your request. The Plan says this request is not medically necessary because you have had enough time to learn a home program so you can practice your skills. The Plan also says that skilled treatment is not needed to maintain your function.  

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 the additional PT 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 the additional requested therapy is not generally accepted as specific and effective therapy for your condition beyond what was approved by the Health Plan. You have had prior therapy of 33 visits outpatient visits 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. Our reviewer found that you have been instructed in and are compliant in a home exercise program and an additional 6 visits to ensure proper transition to an independent home program. Our physician reviewer also found that 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 your 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 the additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional physical therapy (PT) visits (97139).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Praluent for the enrollee.  You asked the Plan to pre-approve this drug. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that this is not covered under Part B.  The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Praluent for the enrollee.   Benefits for this drug 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: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on August 8, 2021.  

You asked the Plan to pay for the ambulance service. You say that you and your husband had both tested positive for the coronavirus. You say that you were in quarantine. You say that you fell and were not able to get back up. You say that you called the ambulance as you had no other option since you had tested positive. You also say that you feel this should be covered. The Plan denied your request. The Plan says there was no transport provided on the date of service in this case. The Plan also says that since no transport was provided, there is no payable service.  

The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.   

The ambulance company did not provide transport services on August 8, 2021. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. 

Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport, (A0998) provided on August 8, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a bladder cancer screening (88121) provided on August 20, 2021.

You asked the Plan to pay for a bladder cancer screening. You say that this was medically necessary. The Plan denied your request. The Plan says this is not a covered screening service.

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, a bladder cancer 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 a bladder cancer screening (88121) provided on August 20, 2021.
Appeal type: Hospice
Decision: Unfavorable

 We decided that the Plan does not have to pay for the hospice long term care services (T2046) provided from July 1, 2021, to July 31, 2021.  You asked the Plan to pay for the long-term care services. The Plan denied your request. The Plan says procedure code T2046 has a status code of I which is not valid for Medicare purposes.  The Plan must follow Medicare rules. Medicare rules say that procedure code T2046 is not valid for Medicare purposes and is not payable.    We looked at the file and Medicare rules. The code at issue, T2046, has an invalid status code and is not payable. Based on this information, we decided that Medicare rules for coverage of the long-term care services have not been met. Therefore, we decided that the Plan does not have to pay for the hospice long term care services (T2046) provided from July 1, 2021, to July 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for hospital discharge day management services (procedure code 99239) provided to the enrollee on October 23, 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 records do not support the services 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 99239 is "Hospital discharge day management; more than 30 minutes." 

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 services at issue in this case were not supported by the medical records. Our reviewer found the medical records provided does not include sufficient documentation to validate that 99239 was performed on October 23, 2020, as there is no duration of 31 minutes or more noted on October 23, 2020, therefore, this service 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 services have not been met. Therefore, we decided that the Plan does not have to pay for hospital discharge day management services (procedure code 99239) provided to the enrollee on October 23, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the core buildup, including any pins when required (D2950),
or pay more for the anterior resin-based composite (D2332) and posterior resin-based composite (D2392)
provided on August 23, 2021, by an OON provider.

You asked the Plan to pay for the core buildup and to pay more for the anterior resin-based composite. You say
that you would like to appeal these services. The Plan denied your request. The Plan says the core buildup is
not a covered expense under your dental plan. The Plan also says that these services were performed by a non-participating
provider, and you are responsible for any difference between the Maximum Allowable Fee and
the amount the provider bills you for the services.

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.

Though the Plan offers a dental benefit in excess of Medicare coverage, core buildup, including any pins when
required (D2950) is not among those covered under this benefit. You are responsible for a 55% coinsurance for
each extraction, plus the difference between the billed amount and allowed amount because these services were
received OON. Therefore, we decided that the Plan does not have to pay for the core buildup, including any
pins when required (D2950), or pay more for the anterior resin-based composite (D2332) and posterior resin-based
composite (D2392) provided on August 23, 2021, by an OON provider.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.  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 the enrollee does not require the intensity of services provided at an IRF. Specifically, the enrollee is not shown to require fifteen hours per week of rehabilitative services and regular physician evaluation. The enrollee's care needs can be met at 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 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.