Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services rendered on January 17, 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 procedure codes 99100 and 99140 are not separately payable.
The Plan must follow Medicare rules. The rules say that payment for codes with a status indicator of B is always bundled into payment for other services not specified. We looked at the file and Medicare rules. Billed procedure codes 99100 (special anesthesia services) and 99140 (anesthesia complicated by emergency conditions) have a status indicator of B and no separate Medicare payment. Therefore, we decided that the Plan does not have to pay for the anesthesia services rendered on January 17, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on June 28, 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 were not billed correctly.
The Plan must follow Medicare rules. The rules say that laboratory shall not report multiple individual CPT codes describing the component test results. We looked at the file and Medicare rules. The file shows that the testing at issue has component test results and was not billed as one test under code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on June 28, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued inpatient psychiatric services from December
11, 2021, forward.
You asked the Plan to pre-approve continued inpatient psychiatric care. You say that the enrollee requires
additional time in the inpatient psychiatric setting. The Plan denied your request. The Plan says they have
agreed to cover care through December 10, 2021, but continued psychiatric care at the inpatient level is not
medically necessary beyond this date. The enrollee can be discharged to an alternate setting.
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 continued inpatient psychiatric care.
Our reviewer says that the health plan's denial of continued psychiatric services at the inpatient level is
appropriate in this case. Our physician reviewer found that the enrollee was admitted to the acute inpatient
psychiatric hospitalization on November 11, 2021, with Major Neurocognitive Disorder, Unspecified with
Behavioral Disturbance. Based upon review of the records provided, it was not expected this enrollee would
improve in a reasonable period of time for the dates in question as she did not have suicidal or homicidal
ideation noted and no auditory or visual hallucinations. This enrollee did not show any abnormal behaviors or
any symptoms which would require acute treatment. It did not appear medically necessary and reasonable to
have psychiatric care provided at the acute inpatient level of care rather than a lower level of care beyond the
dates in question as she did not have dangerousness to self or others but was compliant with her treatment It did
not appear that active treatment was taking place beyond the date in question. It did not appear that the services
were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis beyond the date in
question. Based on the records provided, this enrollee does not meet the criteria for continued acute inpatient
mental health treatment for the dates in question of December 11, 2021, forward.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of continued inpatient psychiatric care have not been met. Therefore, we decided
that the Plan does not have to pre-approve continued inpatient psychiatric services from December 11, 2021,
forward.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
You asked the Plan to pre-approve a power seat elevation feature. You say that this is medically necessary. The Plan denied your request. The Plan says that this is a non-covered feature because it is not primarily medical in nature.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
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 require physical therapy and occupational therapy services but
based on the medical records provided, the enrollee does not require an intensive inpatient rehabilitation
therapy program. There is concern that the enrollee will not be able to fully participate in and benefit from the
intensive rehabilitation therapy program provided in an inpatient rehabilitation facility due to his level of pain
and functional limitations. Care at the skilled nursing facility level appears to be appropriate 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 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cinacalcet rendered on January 3, 2021 to March 31,
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 separately payable.
The Plan must follow Medicare rules. The rules say that all drugs and biologicals used for the treatment of
ESRD are included in the ESRD PPS and are not separately paid.
We looked at the file and Medicare rules. The file shows that the services at issue were performed for the treatment of end-stage renal disease (ESRD). 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 Cinacalcet rendered on January 3, 2021 to March 31, 2021
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the chest x-ray rendered on February 3, 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 claim is a duplicate.
The Plan must follow Medicare rules. The 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 file shows that the services at issue were previously paid by the
Plan on a separate claim for the same date of service. The Plan approved one unit of the services. There is no
documentation to support further units of these services. Therefore, we decided that the Plan does not have to
pay for the chest x-ray rendered on February 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services rendered on November 7, 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 are not covered.
The Plan must follow Medicare rules. The rules say that a professional component (PC)/technical component (TC) indicator of 3 represents TC only codes. We looked at the file and Medicare rules. Billed procedure code 99153 has a PC/TC indicator of 3 and no separate PC payment.
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 99152 is moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older.
We find that CPT code 99152 is not supported in the medical record. Specifically, there is no documentation of an initial 15 minutes of an independent trained observer to assist in monitoring the patient's consciousness and physiological status. 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 moderate sedation services rendered on November 7, 2020.
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 does not meet criteria. 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 is receiving appropriate care at the present acute care hospital. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. 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: Favorable

We decided that the Plan has to pre-approve lumbar epidural injections for the enrollee.
You asked the Plan to pre-approve the injections. You say that this is medically necessary. The Plan denied your request. The Plan says that steroids should be used only in the presence of radiculopathy.
The Plan must follow Medicare rules. Medicare rules say that if there are no specific coverage rules for an item or service, then that item or service will be covered when it is 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 injections. Our reviewer says that the requested services are considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee has documented cervical spinal stenosis at multiple levels. The request is medically reasonable and 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 the injections have been met. Therefore, we decided that the Plan has to pre-approve lumbar epidural injections for the enrollee.
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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for facet joint injections provided on July 12, 2021.
You asked the Plan to pay for facet joint injections 64494. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 64494 has a medically unlikely edit (MUE) value of 1 meaning it cannot be billed with more than 1 unit.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT code 64494 is 1. The MAI value for this code is 2. You billed 2 units of this code, reporting the bilateral procedure with one unit each of 64494-LT and 64494-RT, exceeding the MUE. This procedure is covered for bilateral surgery billing, but it would be appropriate to bill a single unit of the code with the bilateral modifier as 64494-50. Based on this information, we decided that Medicare rules for coverage of facet joint injections 64494 have not been met. Therefore, we decided that the Plan does not have to pay for facet joint injections provided on July 12, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there have been no specific studies done to show that the basivertebral nerve is the cause of the pain.
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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this procedure is experimental. More research is needed to show safety and efficacy of the procedure to treat back pain. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the initial hospital care rendered on March 15, 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 claim is a duplicate.
The Plan must follow Medicare rules. The 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 file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. The Plan approved one unit of the code. There is no documentation to support further units, as billed. Therefore, we decided that the Plan does not have to pay for the initial hospital care rendered on March 15, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (76376) provided on July 26, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 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. In this case, we have confirmed that code 76376 is a column II code to column I code 78306. 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 the services (76376) provided on July 26, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the psychotherapy services (90837 and 99354) provided on June 17, 2021, through July 2, 2021.
You asked the Plan to pay for the psychotherapy services. You say that you would like reconsideration because you were referred to this provider and would like to be reimbursed. The Plan denied your request. The Plan says this provider has opted out of the Medicare program.
The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.
The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the psychotherapy services (90837 and 99354) provided on June 17, 2021, through July 2, 2021.
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 you need aggressive physical therapy now that you can bear weight on your left foot. You could lose momentum and become bedridden if your request is denied. The Plan denied your request. The Plan says based on Medicare guidelines, the requested IRF services do not meet the requirements for approval.
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 based on the medical records provided 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 do require physical therapy and occupational therapy services but based on
the medical records provided you do not require an intensive inpatient rehabilitation therapy program. Based on
the medical records provided there is no documentation that you require the intensive rehabilitation therapy
program provided in an inpatient rehabilitation facility. A lower level of care appears to be appropriate 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 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: Drugs
Decision: Unfavorable

decided that the Plan does not have to pre-approve Eliquis, 5 mg tablet.
You asked the Plan to pre-approve Eliquis. You say that the requested drug is medically necessary. The Plan
denied your request. The Plan says the requested drug is considered self-administered. The Plan says selfadministered
drugs are covered under a Medicare Part D prescription drug plan. The Plan also says the
requested drug is not covered under Medicare Part B.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for selfadministered
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 Eliquis, 5 mg tablet.
Benefits for Eliquis 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: Favorable

We decided that the Plan has to pay for the tissue exam (88305) provided on January 30, 2020.
You asked the Plan to pay for the tissue exam. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that CPT code 88305 is not the appropriate code for the service rendered.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan has not forwarded any medical records to confirm that this code is being billed for a prostate biopsy. Please note, the record indicates that the Plan used medical records to render their decision. It is the burden of the Health Plan to substantiate their denial with evidence. In this case, the denial has not been substantiated so we must find in your favor. Therefore, we decided that the Plan has to pay for the tissue exam (88305) provided on January 30, 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the Cinacalcet rendered from January 3, 2021 to June 30, 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 separately payable.
The Plan must follow Medicare rules. The rules say that all drugs and biologicals used for the treatment of ESRD are included in the ESRD PPS and are not separately paid. We looked at the file and Medicare rules.
The file shows that the services at issue are drugs provided in the treatment of end stage renal disease (ESRD). 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 Cinacalcet rendered from January 3, 2021 to June 30, 2021.