Persius/hicric huggingface dataset:
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 patient requires inpatient rehabilitation facility care. The Plan denied your request. The Plan says the patient does not require three hours of therapy every day and the patient does not need to be seen by a doctor three times a week.  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 the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for gastrointestinal bleeding, anemia, and COVID-19 infection after recent lumbar spine surgery. He was transferred to skilled nursing facility where he is currently being treated. The patient's medical problems are stable and there are no complex nursing or rehabilitation needs. Our doctor says that the patient does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. The doctor also says that 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.  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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional insertion of anterior segment aqueous drainage device provided to the enrollee on May 12, 2021.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says experimental or investigational services are not covered.  The Plan must follow Medicare rules. Medicare rules say that additional insertions of anterior segment aqueous drainage device(s) without extraocular reservoir, via internal approach into the trabecular meshwork are not considered medically reasonable or necessary.   Per the procedure notes, two Stents were delivered on the date of service. 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 additional insertion of anterior segment aqueous drainage device provided to the enrollee on May 12, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the epidurography rendered on May 1, 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 code 72275 is 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 72275 (epidurography) and 62323 (interlaminar injection). Code 72275 is a column II code with a modifier indicator of 1 when billed with column I code 62323. Code 72275 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 epidurography rendered on May 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for a medical vision exam provided on August 26, 2021.  You asked the Plan to waive the copayment for a medical vision exam. You say that that you have never had a copayment before. The Plan denied your request. The Plan says the claim did process according to the Plan benefit.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $40 copayment for Vision Care.    You have been asked to pay a $26.58 copayment (usually a $40 copayment, but less due to the Medicare allowed amount) for a medical vision exam. A medical vision exam falls within the Vision 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 a medical vision exam provided on  August 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing provided on September 9, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the drug testing. 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.  Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care.  The requested provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for the drug testing provided on September 9, 2021 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for fracture treatment (27781) provided on November 20, 2020.  You asked the Plan to pay for fracture treatment. You say that this is supported in the records. The Plan denied your request. The Plan says this is not documented.  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 27781 is closed treatment of proximal fibula or shaft fracture; with manipulation.  We find that CPT code 27781 is not supported in the medical record. Specifically, the submitted records do not document that manipulation was performed. Based on this information, we decided that Medicare rules for coverage of fracture treatment have not been met. Therefore, we decided that the Plan does not have to pay for fracture treatment (27781) provided on November 20, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the needle electromyography (95885) and nerve conduction studies (95907) provided on May 6, 2021.  You asked the Plan to pay for the needle electromyography and nerve conduction studies. 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 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.  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 needle electromyography and nerve conduction studies. Our reviewer says that CPT code 95885 does not meet criteria for billing or reimbursement consideration. The technical report does not include documentation to confirm nerve conduction studies were performed, this procedure would not be covered, as nerve conduction studies are performed with Needle electromyography, each extremity, with related paraspinal areas. Our reviewer found CPT code 95907 does not meet criteria for billing or reimbursement consideration. The technical report does not document nerve conduction studies to include measurement of amplitude, latency, and conduction velocity, therefore this procedure cannot be confirmed as performed.  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 needle electromyography and nerve conduction studies have not been met. Therefore, we decided that the Plan does not have to pay for the needle electromyography (95885) and nerve conduction studies (95907) provided on May 6, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on April 29, 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. 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 65426 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. 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 surgical services rendered on April 29, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for Vitamin B12 injection and electrical stimulation provided to the enrollee on June 29, 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 this denial was appropriate given the clinical scenario.  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 pay for the services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the provided notes did not clearly show evidence of vitamin B12 deficiency, and current evidence of B12 injection or electrical stimulation for the enrollee's condition is not sufficient to support their use in this clinical situation. Therefore, the vitamin B12 and electrical stimulation will be considered not medically 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 services have not been met. Therefore, we decided that the Plan does not have to pay for Vitamin B12 injection and electrical stimulation provided to the enrollee on June 29, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the durable medical equipment (DME) delivery and set up services (A9901) provided on March 26, 2021.  You asked the Plan to pay for the delivery services (A9901). You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this service is included in the payment of other services performed on the same date and no separate payment must be made.  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 A9901 is DME delivery, set up, and/or dispensing service component of another HCSPC code.   We find that CPT code A9901 is not eligible for payment according to Medicare rules. Specifically, this service has a status indicator of "X" under the Physician Fee Schedule which indicates that no payment may be made under the Physician Fee Schedule. Instead, payment is included with other services received on the same date. Based on this information, we decided that Medicare rules for coverage of the delivery services (A9901) have not been met. Therefore, we decided that the Plan does not have to pay for the durable medical equipment (DME) delivery and set up services (A9901) provided on March 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the anesthesia services coded 99100 provided on May 21, 2021.  You asked the Plan to pay for the anesthesia services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable 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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure).    We find that CPT code 99100 is not supported in the medical record. Specifically, this code has a status indicator of "B". A status indicator of B means that payment for this service is always bundled into payment for other services not specified. This means that no separate payment can be made. 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 coded 99100 provided on May 21, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, basic life support, non-emergency
transport (A0428), and ground mileage (A0425) provided on April 8, 2021.
You asked the Plan to pay for the transportation services. You say that the ambulance service was medically
necessary as the enrollee required basic life support (BLS) stretcher transport due to to enrollee safety. The
Plan denied your request. The Plan says the non-emergency ambulance transport was not medically necessary.
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 the transportation services. Our reviewer
says that the transportation services were not medically necessary.
Our physician reviewer found the provided documentation does not indicate that the enrollee could not have
been safely transported by stretcher van or other similar transportation. The reviewer found that the
documentation does not establish the medical necessity and reasonableness, as defined by Medicare rules, of
the requested service. Therefore, the reviewer found that the elements of the coverage criteria are not satisfied.
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 transportation services have not been met. Specifically, the file does not
show that other means of transport were contraindicated for the enrollee. Therefore, we decided that the Plan
does not have to pay for the ambulance service, basic life support, non-emergency transport (A0428), and
ground mileage (A0425) provided on April 8, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued on July 7, 2021.
You asked the Plan to pay for the compression stockings. You say that you have attached the supporting medical records for this date of service. Please review and reprocess accordingly. The Plan denied your request. The Plan says this item is not a covered benefit.
The Plan must follow Medicare rules. The rules say that compression stockings described by code A6533 are noncovered because they do not meet the statutory definition of a surgical dressing. Although this item may be appropriate, it does not fall into a covered benefit category and cannot be paid for by Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the compression stockings identified with code A6533 that were issued on July 7, 2021
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency department services (99285) provided on Jun 21, 2021.  You asked the Plan to pay for the emergency department services. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the required modifier wasn't billed to indicate that the service resulted in the decision to perform the procedure.  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 CPT code 99285 is not supported in the record. Specifically, the record indicates that this service resulted in the decision to render surgery with a 90-day global surgery period. This claim was not billed with the appropriate modifier to indicate that the service resulted in the decision to perform the procedure. Based on this information, we decided that Medicare rules for coverage of the emergency department services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department services (99285) provided on Jun 21, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Freestyle test strips.  You asked the Plan to pre-approve the Freestyle test strips. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the requested strips are non-covered.  The Plan must follow Medicare rules. Medicare rules say that Medicare Advantage (MA) plans may specify brands and manufacturers as preferred and charge lower cost-sharing for the preferred brands or may limit the DME to only those preferred brands and manufacturers.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the Freestyle test strips have not been met. Specifically, the request test strips are not listed as one of the Plan's preferred brands. Additionally, the records do not indicate why this brand would be necessary as opposed to one of the Plan's preferred brands. Therefore, we decided that the Plan does not have to pre-approve the Freestyle test strips.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing facility (SNF) services provided June 6,
2021 to July 5, 2021
You asked the Plan to pay for the SNF services. You say that you feel that the Plan should cover for the SNF
services. The Plan denied your request. The Plan says the enrollee's 100-day skilled nursing facility benefit is
exhausted.
The Plan must follow Medicare rules. The rules say that enrollees are covered for up to 100 days of skilled care
in a SNF in each benefit period. A benefit period begins on admission to a hospital or to SNF level of care and
ends when the enrollee has gone 60 days in a row without inpatient hospital or SNF care.
The file shows that you received 100 days of SNF care during the benefit period from February 11, 2021 to
June 29, 2021. The Plan has covered 100 days of SNF care.
Although you may still need skilled care, the Plan is not required to pay for more than 100 days of SNF
coverage during this benefit period. You will be eligible for a new benefit period when you have not been
receiving care in a hospital or skilled care in a SNF for at least 60 days in a row. Therefore, we decided that the
Plan does not have to pay for the skilled nursing facility (SNF) services provided June 6, 2021 to July 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (81240, 81241, 81291) provided on
July 2, 2021.
You asked the Plan to pay for the laboratory services. You say that you would like reconsideration because this
testing is medically necessary. The Plan denied your request. The Plan says Medicare denies coverage when a
laboratory assays two or more genes in a patient in parallel.
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 pay for the laboratory services. Our reviewer says
that the requested items/services are not considered medically reasonable and necessary in this case. Our
physician reviewer found the documentation does not include specific clinical rationale for the requested
laboratory services. The outcome of this testing would not effect the member's 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 the laboratory services have not been met. Therefore, we decided that the Plan
does not have to pay for the laboratory services (81240, 81241, 81291) provided on July 2, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from June 24, 2021, to June 29, 2021.  You asked the Plan to waive the copayment for the inpatient hospital services. You say that the private room was the only room available. The Plan denied your request. The Plan says you have been charged the correct cost sharing amount.  The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay $289 per day for days 1-6 and $0 per day for days 7-90 for each inpatient stay.     The record shows you were in the hospital from June 24, 2021, to June 29, 2021, but there is no copayment for the discharge date. Therefore, you have been asked to pay $289 per day for the first five days of inpatient hospital services. The total for your stay is $1445. You are not being charged extra for a private room. Inpatient hospital services fall 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 inpatient hospital services provided from June 24, 2021, to June 29, 2021.