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 these services are medically necessary. The Plan denied your request. The Plan says that your records do not show you need an intensive program with a team of health care professionals and doctors that specialize in complex medical needs as well as rehab.  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 your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for ventral hernia repair, deep vein thrombosis, and placement of IVC filter. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer found that your 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.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for a LDCT scan for lung cancer screening, provided on April 14, 2021.  You asked the Plan to pay for the requested LDCT scan. The Plan denied your request. The Plan says a LDCT is experimental or investigational and not covered.   The Plan must follow Medicare rules. The rules say that Medicare covers one annual LDCT scan for lung cancer screening for enrollees who meet all the criteria described in the Medicare rules section of this letter.   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 LDCT scan. Our reviewer says that a LDCT scan is not medically necessary. Our physician reviewer found that the use of LDCT (71271) is reserved for asymptomatic patients with no prior abnormality to follow, thus a lung cancer screening exam is inappropriate. A follow-up of various nodules should have been done with a CT of the chest without contrast (71250).  We looked at this physician's review, the file, and Medicare rules. We find that the use of LDCT is reserved for asymptomatic patients with no prior abnormality to follow, thus a lung cancer screening exam is inappropriate. Therefore, we decided that the Plan does not have to pay for a LDCT scan for lung cancer screening, provided on April 14, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided on May 13, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says the records do not support additional lab results.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We looked at the file and the rules. The file shows that hematocrit (85014), platelet blood count (85049), hemoglobin (85018), and 4 additional units of a complete blood count (CBC 85027) were billed on the date of service at issue. We find that the CPT codes are not supported in the medical record.  The records provided do not show that the services billed were provided. The records do not show that additional units of code 85027 were provided. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided on May 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF). You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says care can be provided in a less intensive setting of care, for example, at a skilled nursing facility, or home with supervision and home health, assisted living facility with home health or long-term care and intermittent services.    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 there are no complex rehabilitation needs. There is no need for periodic functional or medical assessment. You are wearing a stabilizing walker boot, and have good ambulatory capacity. You can be safely managed in the home setting. Your medical complexity does not justify the requested admission. It will amount to over treatment and unnecessary care. It will expose you to IRF-setting complications and infections. You would not be able to fully benefit and participate in the admission.  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 admission to an inpatient rehabilitation facility (IRF).
Appeal type: Supplemental Benefit
Decision: Favorable

 We decided that the Plan has to pre-approve service dog services provided by an out-of-network provider.  You asked the Plan to pre-approve service dog services. You say that the enrollee's dog meets the America Disability Act definition for one that was individually trained to help the member dealing with PTSD. The Plan denied your request. The Plan says that the enrollee does not qualify for this benefit.  The Plan must follow Medicare rules. Medicare rules say that there is a special supplemental benefit for enrollees with an eligible chronic condition.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a service dog have been met. Specifically, the record clearly indicates that the member has major depressive disorder which is an eligible condition listed in the Evidence of Coverage.  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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for drug testing services provided to the enrollee on November 10, 2020.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain 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.  We find that the various denied codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a doctor's office (POS 11). 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 drug testing services provided to the enrollee on November 10, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pay for the saline infusion provided on April 1, 2021.  You asked the Plan to pay for the saline infusion. You say that supporting documentation is attached and the claim should be reprocessed. The Plan denied your request. The Plan says this is considered incidental hydration and is not separately reported or separately reimbursed.  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 J7040 is infusion, normal saline solution, sterile (500 ml = 1 unit).    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 saline infusion. Our reviewer says that the submitted documentation was reviewed and does not meet criteria for coverage. Our reviewer found that fluid used to administer drug(s) is incidental hydration and is not separately payable.  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 saline infusion have not been met. Therefore, we decided that the Plan does not have to pay for the saline infusion provided on April 1, 2021.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Belbuca (J8499).  You asked the Plan to pre-approve Belbuca. You say that Belbuca is medically necessary for the enrollee's back pain. The Plan denied your request. The Plan says the requested drug is considered self-administered. The Plan says self-administered 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 self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Belbuca (J8499).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for imaging services (procedure code 74176) provided to the enrollee on July 10, 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 an appropriate modifier was not billed in this case.  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 74176 is a column II code to column I code 74177. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for imaging services (procedure code 74176) provided to the enrollee on July 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care with drug related group (DRG) 682 provided from December 7, 2020 to December 27, 2020.  You asked the Plan to pay for the inpatient hospital care. You say that the medical records support the billing of the primary diagnosis code N17.9 or secondary diagnosis code G92 with DRG 682. The Plan denied your request. The Plan says the medical records do not support the billing of the primary diagnosis code N17.9 or secondary diagnosis code G92 with DRG 682.  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 primary diagnosis code N17.9 or secondary diagnosis code G92. 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 care. Our reviewer says that the medical records do not support the billing of the primary diagnosis code N17.9 or secondary diagnosis code G92 with DRG 682. Our physician reviewer found the enrollee has a history of vascular dementia, schizophrenia, hearing loss, seizure disorder, cerebral vascular accident (CVA) with left-sided deficit, metastatic prostate cancer and chronic kidney disease (CKD) Stage III who presented to the emergency department (ED) on December 7, 2020 for evaluation of decreased oral intake and visual hallucinations. In the ED he was described as awake and alert x 3. Labs revealed a creatinine of 2.7/BUN35. The urinalysis was concerning for infection. A computed tomography (CT) scan of the head revealed no acute abnormalities. Renal ultrasound revealed mild to moderate right hydronephrosis with an enlarged prostate and a non-obstructing left renal calculus. He was treated with fluids and IV antibiotics and a Foley catheter was placed. He has periods of agitation consistent with his dementia diagnosis. His creatinine decreased to 2.4 with medical therapy.  The review has determined that the records did not support the billing of DRG 682 with primary diagnosis code N17.0 and secondary diagnosis code G92.   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 care with drug related group (DRG) 682 provided from December 7, 2020 to December 27, 2020.
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 IRF care is medically reasonable and necessary. The Plan denied your request. The Plan says rules for IRF care have not been met.  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 the patient was admitted for metabolic encephalopathy and Non-ST-elevation myocardial infarction (NSTEMI). 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 patient has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. In conclusion, 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: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient behavioral health services provided from February 12, 2021, to February 15, 2021.  You asked the Plan to pay for the inpatient behavioral health services provided from February 12, 2021, to February 15, 2021. You say that the services provided were medically necessary. The Plan denied your request. The Plan says the enrollee did not have acute symptoms that required 24 hour inpatient psychiatric care from February 12, 2021, to February 15, 2021.  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 pay for the inpatient behavioral health services provided from February 12, 2021, to February 15, 2021. Our reviewer says that the behavioral health services are not medically necessary. Our physician reviewer found the provided documentation shows that you did not appear to require inpatient mental health treatment beyond the date in question as you were not a danger to yourself or others and did not have any delusions, auditory or visual hallucinations while being cooperative with treatment. The reviewer found that the services were reasonably expected to improve your condition or for the purpose of diagnosis beyond the date in question. Therefore, the reviewer found that the inpatient behavioral health services were 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 the inpatient behavioral health services provided from February 12, 2021, to February 15, 2021, have not been met. Specifically, the file shows that you were not a danger to herself or others and did not have any delusions, auditory or visual hallucinations while being cooperative with treatment. Therefore, we decided that the Plan does not have to pay for the inpatient behavioral health services provided from February 12, 2021, to February 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (73630) provided on July 15, 2021.  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. The two exceptions are for enrollees who are registered hospital inpatients or outpatients, in which case, the inpatient or outpatient hospital POS code would be reported regardless of where the face-to-face service takes place.   We looked at the file and Medicare rules. In this case, the records show that the enrollee was under inpatient status when the services were provided. This means that it is inappropriate to bill the services with an outpatient place of service (POS) code (22). 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 (73630) provided on July 15, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chiropractic services provided on September 24, 2020.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services are not covered when provided by a chiropractor.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).  You asked the Plan to pre-approve RFA. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  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 RFA. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found radiofrequency ablation for denervation, whether performed using traditional, cooled, or pulsed radiofrequency, is considered investigational and therefore, not medically necessary. The review has determined that the requested sacroiliac joint RFA is not medically necessary or reasonable.         We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of RFA have not been met. Therefore, we decided that the Plan does not have to pre-approve radiofrequency ablation (RFA).
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the abdominal ultrasound rendered on July 25, 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 76705 (abdominal ultrasound) and 93976 (vascular study). Code 76705 is a column II code with a modifier indicator of 1 when billed with column I code 93976. Code 76705 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 abdominal ultrasound rendered on July 25, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lab services provided to you on April 30, 2021.  You asked the Plan to pay for the lab services. The Plan denied your request. The Plan says records were not provided.  The Plan must follow Medicare rules. Medicare rules say that the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have been met.   We looked at the file and Medicare rules. The submitted documentation does not contain medical records from the non-contract provider. Without records, it cannot be determined that Medicare coverage criteria have been met. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for the lab services provided to you on April 30, 2021.