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

We decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on May 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 rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.
The provider submitted a claim for procedure codes 70450 (CT head/brain) and 70496 (computed tomography angiography of the head). Code 70450 is a column II code with a modifier indicator of 1 when billed with column I code 70496. Code 70450 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan of the head/brain rendered on May 31, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided May 14, 2021, to May 15, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that the enrollee presented to the emergency department due to severe abdominal pain, nausea and vomiting. Pain was localized to the right groin area, sharp and related to constipation. The Plan denied your request. The Plan says the request is not medically necessary because records show the enrollee did not have emergency surgery and the enrollees condition improved within a period of observation.
The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the hernia was manually reduced in the emergency room and the enrollee's symptoms resolved with quick return to oral intake. Surgical consultation was obtained, and the member was discharged for outpatient follow up and elective hernia repair. The record did not show that at the time of inpatient admission the admitting physician reasonably expected that the patient's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided May 14, 2021, to May 15, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for non-emergent ambulance transport (A0428, A0425) provided on June 22, 2021.
You asked the Plan to pay for non-emergent ambulance transport. You say that the services at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says medical necessity rules for the services at issue were not met.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. 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 non-emergent ambulance transport. Our reviewer says that the services at issue were not medically reasonable and necessary. Our physician reviewer found that the enrollee did not require the expertise of trained personnel or the equipment available only on an ambulance in order to effectuate a safe transport. Transportation could have been provided by other means (stretcher van, wheelchair van, private car, taxi) without endangering the 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 non-emergent ambulance transport have not been met. Therefore, we decided that the Plan does not have to pay for non-emergent ambulance transport (A0428, A0425) provided on June 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services billed with DRG 871 and provided on January 7, 2020, through January 14, 2020.
You asked the Plan to pay for the inpatient hospital services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support a primary diagnosis of sepsis, unspecified organism.
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 871 with a primary diagnosis of A41.9. 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. Our reviewer says that the medical record received did not support the condition treated as consistent with a systemic infectious process. The review has determined that the documentation did not support DRG 871 with a primary diagnosis of sepsis, unspecified organism. Our physician reviewer found while the member's presentation warranted consideration of sepsis as a diagnosis, there was no evidence of life-threatening organ dysfunction due to a dysregulated host response to infection. 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 the inpatient hospital services billed with DRG 871 and provided on January 7, 2020, through January 14, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve LTACH services.
You asked the Plan to pre-approve the LTACH services. You say that the admission to an LTACH is medically
necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically
necessary.
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 records show that 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve compression stockings identified with code A6531. You asked the Plan to pre-approve the compression stockings. You say that you require the compression stockings. The Plan denied your request. The Plan says that there is no evidence of a qualifying wound or venous stasis ulcer requiring surgical treatment.
The Plan must follow Medicare rules. Medicare rules say that compression stockings described by code A6531 are covered only when they are used to treat an open venous stasis ulcer. Medicare rules also say that compression bandages and gradient compression wraps are covered only when they are used as dressings over a qualifying wound. The record does not show that you have open venous stasis ulcers or a qualifying wound. This means that you do not have a medical condition for which compression stockings can be covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve compression stockings identified with code A6531.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the adjacent tissue transfer or rearrangement (14302x5)
provided on August 17, 2020.
You asked the Plan to pay for the adjacent tissue transfer. You say that you would like reconsideration based
on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not
support the service billed.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.
In this case, the CPT Code Manual definition of code 14302x5 is adjacent tissue transfer or rearrangement, any
area; each additional 30.0 sq cm, or part thereof (List separately in addition to code for primary procedure). 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 adjacent tissue transfer. Our reviewer says that CPT code
14302 does not meet criteria for billing or reimbursement consideration. Our reviewer found the operative
report does not include enough detail to confirm a adjacent tissue transfer was performed. Documentation
describes undermining, and not the tissue transfer. Therefore, this procedure cannot be confirmed.
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 adjacent tissue transfer have not been met. Therefore, we decided that the
Plan does not have to pay for the adjacent tissue transfer or rearrangement (14302x5) provided on August 17,
2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the debridement services rendered on October 23, 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 procedure codes 11721 and 11056 are 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 11721 is debridement of nail(s) by any method(s); 6 or
more. The definition of code 11056 is paring or cutting of benign hyperkeratotic lesion (eg, corn or callus); 2 to
4 lesions.

We find that CPT codes 11721 and 11056 are not supported in the medical record. Specifically, there is no
documentation of debridement of nails by any method, 6 or more, to support code 11721.

There is no documentation of paring or cutting of benign hyperkeratotic lesions to support code 11056. 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 debridement services rendered on October 23,
2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug testing services provided on November 24, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.
The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service. We looked at the file and Medicare rules. The documentation shows that the services in question were billed
with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 drug testing services provided on November 24, 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 transfer to an LTACH is medically necessary for this enrollee, and they cannot go to a nursing facility. The Plan denied your request. The Plan says the criteria for admission to an LTACH have not been met. The enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional services. With additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.
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 acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where they are currently receiving care. The documentation is insufficient to demonstrate that the requested LTACH services are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee at this time.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) services provided to the enrollee from May 22, 2021 to June 20, 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 there was no documentation of therapy or new skilled nursing needs.

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 pay for the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee did 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 during the dates of May 22, 2021 to June 20, 2021. The documentation indicates that the enrollee was taking oral medications and dieting. He had chronic wounds with every other day dressing changes. He was non-compliant with wound care and other services such as glucose monitoring. The enrollee's functional level did 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. The enrollee did 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, the enrollee did not require the necessary services on an inpatient basis, in a skilled nursing facility setting during the dates of service in question. 

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 pay for skilled nursing facility (SNF) services provided to the enrollee from May 22, 2021 to June 20, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the overpayment recovery request for the hearing aids and dispensing fee provided on February 24, 2021.
You asked the Plan to waive the overpayment recovery request for the hearing aids and dispensing fee. You say that you cashed the check and submitted the money to the provider as soon as possible. You say that you are expected to send the money back but would be willing to return the hearing aids. The Plan denied your request. The Plan says payment was issued in error and should be returned in full.
Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for hearing aids only when they are received from the Plan's hearing vendor.
We looked at the case file and the Plan's rules. Based on this information, we decided that the request to waive the overpayment recovery has not been met. Therefore, we decided that the Plan does not have to waive the overpayment recovery request for the hearing aids and dispensing fee provided on February 24, 2021.
Appeal type: Testing
Decision: Favorable

We decided that the Plan has to reduce the copayment for the diagnostic tests (94727, 94060, 94729) provided on February 1, 2021, from $100 to $10.
You asked the Plan to reduce the copayment for the diagnostic tests. You say that you should only owe a $10 copayment for these services, which were provided by your primary care physician. The Plan denied your request. The Plan says that this claim processed correctly according to your benefits. You are required to pay a $100 copayment for diagnostic services performed in an outpatient hospital setting.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information. Your contract with the Plan says that enrollees must pay a $10 copayment for diagnostic procedures and tests performed in a primary care physician's office. The Plan says you must pay a $100 copayment for the diagnostic tests. Based on the Plan contract, however, you cannot be asked to pay more than a $10 copayment for the diagnostic tests. The Plan says that this copayment was assessed correctly, and you owe $100 for diagnostic tests and procedures performed in an outpatient hospital setting. However, there is no evidence that these services were performed in a hospital setting. The provider in this case is your primary care physician, and the facility on the claim form is not a hospital. Therefore, we decided that the Plan has to reduce the copayment for the diagnostic tests (94727, 94060, 94729) provided on February 1, 2021, from $100 to $10.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (S9097) provided on April 10, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this code is not
payable.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee
Schedule indicates that the code in question is not valid for Medicare purposes.

We looked at the file and Medicare rules. Code S9097 is assigned a status indicator of "I" under the Physician
Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for
reporting of, and payment for, these services. 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 (S9097) provided on April 10, 2021.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (43235) provided on February 19, 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 43235
has a bundled relationship with code 43820 and cannot be paid as billed. This code cannot be paid as a separate
line item. 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 (43235) provided on February 19, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Aduhelm for the enrollee.
You asked the Plan to pre-approve Aduhelm. You say that this is medically necessary for the enrollee. The Plan denied your request. The Plan says that the submission included no validated objective rating scale showing mild cognitive impairment or mild dementia.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved drugs if they are medically accepted as safe and effective or appropriate for the particular use. 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 Aduhelm. Our reviewer says that Aduhelm is not medically reasonable and necessary for the enrollee. Aduhelm is FDA-approved for the treatment of Alzheimer's disease. Treatment with Aduhelm should be initiated in patients with mild cognitive impairment or mild dementia stage of disease. The evidence that the enrollee has a diagnosis of Alzheimer's disease is inconsistent. The use of Aduhelm is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal for the enrollee's condition. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of Aduhelm. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of Aduhelm have not been met. Therefore, we decided that the Plan does not have to pre-approve Aduhelm for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an endoskeletal system (L5910) and componentry parts (L5999).
You asked the Plan to pre-approve an endoskeletal system and componentry parts. You say that these items are medically necessary. The Plan denied your request. The Plan says these items are duplicative.
The Plan must follow Medicare rules. The rules say Medicare covers DME only when it is reasonable and necessary. If DME serves the same purpose as equipment already available to an enrollee, it is not considered reasonable and necessary. The file shows that the requested items are included in your current prosthesis and the approved accessories
and cannot be separately approved. Therefore, we decided that the Plan does not have to pre-approve an endoskeletal system (L5910) and componentry parts (L5999).