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

We decided that the Plan does not have to waive the coinsurance for the office visit (99214) provided on
June 21, 2021.
You asked the Plan to waive the coinsurance. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the coinsurance has been applied correctly to the service provided.
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 50% of the total cost for Medicare-covered physician specialist services rendered by an out-of-network provider.
You have been asked to pay $58.81(Plan allowed amount of $117.62 x 50% coinsurance) for the Medicare-covered specialist office visit provided as this service was rendered by an out-of-network provider. 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 coinsurance for the office visit (99214) provided on June 21, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services (99100 and 99140) provided on 
December 25, 2020. 
 
You asked the Plan to pay for the anesthesia services. You say that you would like these claims reprocessed 
based on the medical records. The Plan denied your request. The Plan says these claims are always bundled 
into payment for other services not specified and no separate payment. 
 
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 99100 Anesthesia for patient of extreme age, younger 
than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). The CPT 
Code Manual Definition of code 99140 is anesthesia complicated by emergency conditions (specify) (List 
separately in addition to code for primary anesthesia procedure).  
 
We find that CPT code 99100 and 99140 are not supported in the medical record. Specifically, CPT code 
99100 and 99140 have a status indicator of B meaning that payment for these services is always bundled into 
another procedure. Separate payment is not made for CPT codes 99100 and 99140. Based on this information, 
we decided that Medicare rules for coverage of the anesthesia services have not been met. Therefore, we 
decided that the Plan does not have to pay for the anesthesia services (99100 and 99140) provided on 
December 25, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services coded as 
99239 provided on September 3, 2020. 
 
You asked the Plan to pay for the hospital discharge day management services. You say that the medical 
records support the services as billed. The Plan denied your request. The Plan says the documentation does not 
corroborate the code 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. 
 
In this case, the CPT Code Manual definition of code 99239 is hospital discharge day management; more than 
30 minutes We find that CPT code 99239 is not supported in the medical record. Specifically, the medical records do not 
support that more than 30 minutes were spent on the hospital discharge day management services. There is no 
documentation that records the amount of time that was spent on these services. Based on this information, we 
decided that Medicare rules for coverage of the hospital discharge day management services have not been met. 
Therefore, we decided that the Plan does not have to pay for the hospital discharge day management services 
coded as 99239 provided on September 3, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the inpatient hospital stay provided July 9, 
2019 to July 15, 2019. 
 
You asked the Plan to waive the copayment for the inpatient stay. You say that it has been 2 years since this 
incident and the hospital is just now sending you a bill. The Plan denied your request. The Plan says the claim 
was processed with the correct copayment applied per the Evidence of Coverage. 
 
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 $200 
copay per day for days 1-7 for Medicare covered hospital stays.  
 
You have been asked to pay $1,069.80 ($200 x 6 days) for the inpatient stay. You are only being charged 
$1,06980 as a prorated copayment amount for these services. The inpatient stay falls within the Inpatient 
hospital care 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 the inpatient hospital stay 
provided July 9, 2019 to July 15, 2019.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve use of pegloticase and hydrocortisone.
You asked the Plan to pre-approve pegloticase and hydrocortisone. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of authorization for these drugs is correct, because the enrollee has normal uric acid controlled by current medications and these drugs are not medically necessary.
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 pegloticase and hydrocortisone. Our reviewer says that the enrollee does not meet the Medicare criteria for the requested use of pegloticase and hydrocortisone. Our physician reviewer found the requested use of pegloticase and hydrocortisone is not Food & Drug Administration (FDA) approved for the enrollee's diagnosis. Pegloticase is not recommended for the treatment of high levels of uric acid in the blood. This use is not supported by one of the major drug compendia or by clinical research appearing in a Medicare-approved medical journal.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of pegloticase and hydrocortisone have not been met. Therefore, we decided that the Plan does not have to pre-approve use of pegloticase and hydrocortisone.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the diagnostic radiology services coded as 75625 and 75710 
-59 provided on April 5, 2021. 
 
You asked the Plan to pay for the diagnostic radiology services. You say that the medical records support the 
codes as billed. The Plan denied your request. The Plan says the medical records do not corroborate 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. The rules state that providers may bill services 
with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. In this case, the CPT Code Manual definition of code 75625 is aortography, abdominal, by serialography, 
radiological supervision and interpretation. The CPT Code Manual definition of code 75710 is angiography, 
extremity, unilateral, radiological supervision and interpretation. 
 
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 diagnostic radiology services Our reviewer says that the 
billed codes are not supported in the medical records submitted. Our physician reviewer found that regarding 
code 75625, the criteria for coverage have not been met. The medical records provided do not include sufficient 
documentation to validate that an aortography, abdominal, by serialography, radiological supervision and 
interpretation was performed on April 5, 2021, therefore this service cannot be verified. Our reviewer also 
found that the criteria for 75710 with a -59 modifier also have not been met. The medical records provided do 
not include sufficient documentation to validate the angiography, extremity, unilateral, radiological supervision 
and interpretation performed on April 5, 2021, was a distinct, separate procedure from CPT 37225 LT that was 
performed on the same day, by the same provider during the same operative session.  Therefore CPT 75710 is 
considered inclusive to CPT 37225 and the use of a 59 modifier, in this case, is inappropriate. 
 
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 diagnostic radiology services have not been met. Therefore, we decided that 
the Plan does not have to pay for the diagnostic radiology services coded as 75625 and 75710 -59 provided on 
April 5, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve PT visits.
You asked the Plan to pre-approve additional PT visits. You say that additional PT is medically necessary. The Plan denied your request. The Plan says additional PT is not medically necessary.
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 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 that based on the available records you appear to have plateaued with therapy. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in the patient's symptoms or functional status. Further skilled therapy at this point does not appear to be likely to achieve any significant improvement in your symptoms or functional status. Further utilization of the home exercise program appears appropriate at this point. There is no documentation 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 under the supervision of a therapist. There is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is 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 additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve additional PT visits.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient hospital services provided from May 16, 2021, to May 23, 2021.
You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the primary diagnosis code was found to be inappropriate.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. The claim shows the services at issue were billed with a primary diagnosis code F01.51, vascular dementia with behavioral disturbance. We looked at the file and the rules. Based on this information, we decided that the rules for sequencing have not been met. Therefore, we decided that the Plan does not have to pay for the inpatient hospital services provided from May 16, 2021, to May 23, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography scan represented by code 70450 provided on June 26, 2021.
You asked the Plan to pay for code 70450. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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. In this case, we have confirmed that code 70450 has a bundled relationship with code 70496 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 computed tomography scan represented by code 70450 provided on June 26, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on February 1, 2021.

You asked the Plan to pay for the laboratory services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 laboratory services at issue in this appeal were 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 provided on February 1, 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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF is 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 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 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 not require
treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive
rehabilitation therapy program. While the documentation does support a need for physical and/or occupational
therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program.
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 pre-approve Keytruda (J9271), 200 units for 4 visits.
You asked the Plan to pre-approve Keytruda. You say that the request for Keytruda is medically necessary. The Plan denied your request. The Plan says there is no documentation of PD-L1 testing. The Plan also says that the requested drug is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for anti-cancer 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 Keytruda. Our reviewer says that Keytruda is not medically necessary. Our physician reviewer found there is no documentation that the requested use of Keytruda is Food and Drug Administration (FDA) approved for the enrollee's diagnosis.
The reviewer found that the provided documentation indicated the tumor specimen metastatic to the liver was negative for programmed death-ligand 1 (PD-L1) expression with a combined positive score (CPS)<1. The reviewer found that the use of Keytruda for metastatic triple-negative breast cancer whose tumors do not express PD-L1 is not supported by one of the major drug compendia or by clinical research that appears in a Centers for Medicare & Medicaid Services (CMS) approved medical journal. Therefore, the reviewer found that Keytruda is 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 Keytruda have not been met. Specifically, the record shows that Keytruda is not FDA-approved for the enrollee's diagnosis. Therefore, we decided that the Plan does not have to pre-approve Keytruda (J9271), 200 units for 4 visits.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve the SNF services. You say that the documentation provided supports the need for SNF care. The Plan denied your request. The Plan says SNF care is not medically necessary.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the SNF services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found the enrollee received oral medications, had stable vital signs, and used oxygen via nasal cannula. The enrollee was dependent for functional mobility and required assistance with activities of daily living. There are no identifiable skilled therapy services. There are no identifiable skilled nursing service needs. The enrollee does not meet the severity of illness or intensity of service criteria for an inpatient basis in a SNF setting. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided from May 2, 2021, through May 3, 2021.

You asked the Plan to pay for acute inpatient hospital care. You say that The Plan denied your request. The Plan says one night hospital stay did not meet the 25th edition of the MCG Guidelines for Anemia, Iron Deficiency or Unspecified (M-35), and Renal Failure, Chronic (M-325), as well as Chapter 1 of the Medicare Manual. The one-night hospital stay was consistent with an observation level of care.

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 that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee'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 from May 2, 2021, through
May 3, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan denied your request. The Plan says that records show that there is no need for an intensive rehabilitation program.
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. The complexity of the patient's nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient has a past medical history of polymyalgia rheumatica, fibromyalgia and depression. She is living at home and received injections in both knees for osteoarthritis on October 15, 2021. She has ongoing weakness. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.