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

We decided that the Plan does not have to pre-approve a referral out-of-network for inguinal hernia surgical repair.

You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says there are contracted providers within the area.

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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.

The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a referral out-of-network for inguinal hernia surgical repair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a cervical selective nerve block for the enrollee.

You asked the Plan to pre-approve the block. You say that this is medically necessary. The Plan denied your request. The Plan says there is no clinical documentation of four weeks of non-invasive care since the recent prior cervical spine surgery.

The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. 

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the block. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found according to the documentation; the enrollee's physical examination reported her bilateral upper extremity strength was normal. The enrollee's Spurling's sign was negative bilaterally. No neurological deficits were noted on physical examination. In this case, there is no record of a specific functional deficit. There is no clinical documentation of 4 weeks of noninvasive care since her recent prior cervical spine surgery. There is no documentation of updated imaging since the enrollee's surgery.

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 block have not been met. Therefore, we decided that the Plan does not have to pre-approve a cervical selective nerve block for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF) for the enrollee.

You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says a lower level of care might be appropriate.

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 enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for surgical repair of a hip fracture after a fall. Medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record supports a need for physical and/or occupational therapy, there is no documented need for intensive rehabilitation services. Medically necessary care can be provided in a different level of care. There is not a reasonable expectation that this enrollee 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 admission to an inpatient rehabilitation facility (IRF) for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for a critical care evaluation visit provided on March 19, 2021.

You asked the Plan to pay for critical care evaluation. You say that the documentation supports the level of care billed for this patient. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the documentation submitted does not support the code 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 99291 is critical care, evaluation and management of the critically ill or critically injured patient; first 30-74 minutes.

We find that CPT code 99291 is not supported in the medical record. Specifically, the records do not support that the critical care evaluation service was 30-74 minutes in duration. Based on this information, we decided that Medicare rules for coverage of critical care evaluation have not been met. Therefore, we decided that the Plan does not have to pay for a critical care evaluation visit provided on March 19, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the removal of spine fixation device provided on February 24, 2021.
You asked the Plan to pay for the removal of spine fixation device. You say that the documents should be considered in support of CPT code 22850 for favorable reprocessing and payment. The Plan denied your request. The Plan says the procedure is ineligible for separate pay.
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 22850 is removal of posterior nonsegmental instrumentation (eg, Harrington rod). 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 removal of spine fixation device. Our reviewer says that this does not meet criteria for billing or reimbursement consideration. Our reviewer found that the medical records provided does not include sufficient documentation to support CPT 22850 was performed as a distinct, separate procedure. 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 removal of spine fixation device have not been met. Therefore, we decided that the Plan does not have to pay for the removal of spine fixation device provided on February 24, 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 enrollee needs rehabilitation to become more independent so that she can go home. You say that the enrollee also needs to move to a facility that does not have any coronavirus cases. The Plan denied your request. The Plan says the enrollee's current medical stability and lack of medical complexity does not warrant care in the IRF.
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 criteria for coverage have not been met.
Our physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee was admitted for infection of right knee arthroplasty and had revision arthroplasty. The enrollee's medical problems are stable. There are no complex nursing or rehabilitation needs. The enrollee 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 a intensive, multi-disciplinary rehabilitation program. There is not a reasonable expectation that this enrollee 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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography coded 70450 provided on May 18, 2021.
You asked the Plan to pay for the computed tomography. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not separately payable.
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 for the computed tomography 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 coded 70450 provided on May 18, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve surgical placement of implants (D6010 x3), and custom
fabricated abutments (D6057 x3).
You asked the Plan to pre-approve surgical placement of implants, and custom fabricated abutments. You say
that you disagree with the denial for these services. The Plan denied your request. The Plan says the services at
issue are covered benefits, but you have exceeded the frequency limit of two every calendar year.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
We looked at the file, and Medicare rules. Based on this information, we decided that the Plan's rules for
coverage of surgical placement of implants, and custom fabricated abutments have not been met. Specifically,
the record shows that you had exceeded the frequency limits for these services on September 2, 2021.
Therefore, we decided that the Plan does not have to pre-approve surgical placement of implants (D6010 x3),
and custom fabricated abutments (D6057 x3).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for a knee sling, shower chair, waterproof cast cover, and grab bars purchased from commercial retailers from March 1, 2021, to March 7, 2021.
You asked the Plan to pay for these items. You say that these items were medically necessary for your safety. The Plan denied your request. The Plan says these items are not covered by Medicare.
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a medical purpose. The items at issue are self-help items and are not covered by Medicare. In addition, items purchased from the internet or from providers who are not eligible Medicare providers are not covered. Therefore, we decided that the Plan does not have to pay for a knee sling, shower chair, waterproof cast cover, and grab bars purchased from retailers from March 1, 2021, to March 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the vaccine coded 90672 provided on January 12, 2021.
You asked the Plan to pay for the vaccine. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 90672 is influenza virus vaccine, quadrivalent, live (LAIV4), for intranasal use.
We find that CPT code 90672 is not supported in the medical record. Specifically, the documentation shows that the enrollee received the intramuscular influenza vaccine and not the intranasal influenza vaccine. This means there is a more appropriate code to be billed for the services rendered. Based on this information, we decided that Medicare rules for coverage of the vaccine have not been met. Therefore, we decided that the Plan does not have to pay for the vaccine coded 90672 provided on January 12, 2021.
Appeal type: Hospice
Decision: Unfavorable

We decided that the Plan does not have to pay for the polymerase chain reaction (PCR) coronavirus test (U0003) provided on January 6, 2021.
You asked the Plan to pay for the PCR test. You say that you are dependent on receiving enrollee information from the ordering provider. The Plan denied your request. The Plan says the enrollee's claim would be covered
under Original Medicare as it is responsible for coverage of Part B benefits starting on the date of election until
the last day of the month in which hospice is revoked. The Plan also says it is the provider's responsibility to
verify the enrollee's coverage before rendering services and to know proper billing procedures for a Medicare
Advantage member on hospice.
Medicare rules say that Original Medicare, not the Plan, is responsible for all Medicare-covered non-hospice
services. Medicare hospice pays for claims related to the terminal illness. The rules say that the Plan may direct
the provider to bill Medicare directly for these services.
The enrollee was under the Medicare hospice benefit for the date of service at issue in this appeal. Therefore,
we decided that the Plan does not have to pay for the polymerase chain reaction (PCR) coronavirus test
(U0003) provided on January 6, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel services coded R0070 provided on April 1, 2021.
You asked the Plan to pay for the transportation of portable x-ray equipment and personnel 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 R0070 is transportation of portable x-ray equipment and personnel to home or nursing home, per trip to facility or location, one patient seen.
We find that CPT code R0070 is not supported in the medical record. Specifically, this code has a professional component/technical component (PC/TC) indicator of 3. This code was billed with place of service 31 (skilled nursing facility). This service should be billed with place of service 32 (nursing facility) since the enrollee was in a non-covered stay. Based on this information, we decided that Medicare rules for coverage of the transportation of portable x-ray equipment and personnel services have not been met. Therefore, we decided that the Plan does not have to pay for the transportation of portable x-ray equipment and personnel services coded R0070 provided on April 1, 2021
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to reimburse an additional amount for the oral exam (D0120), prophylaxis (D1110), periapical x-ray (D0220), and drug or medicament for home use (D9630) provided on February 24, 2021.
You asked the Plan to reimburse an additional amount for the dental services. You say that you paid $185 for the services you received. You say that you received a check for only $36.50. You also say that you do not know what part of the bill it was going toward. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that the oral exam, prophylaxis, and x-ray have a 50% coinsurance when received out of network. The Plan also says that drug or medicament for home use is not listed as a covered service.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. Though the Plan offers a dental benefit in excess of Medicare coverage and oral exam, prophylaxis, and periapical x-ray are listed as covered, the provider in this case is out of network. There is a 50% coinsurance for these dental services received out of network. Out of network providers can also bill you for any amount greater than what the Plan pays the provider. This is a contractual obligation you agreed to when you enrolled in the Plan's dental coverage. Additionally, drug or medicament is not among those covered under this benefit. Therefore, we decided that the Plan does not have to reimburse an additional amount for the oral exam (D0120), prophylaxis (D1110), periapical x-ray (D0220), and drug or medicament for home use (D9630) provided on February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to reimburse you for a CPAP machine and nasal mask purchased on March 18, 2021 from a non-certified provider.
You asked the Plan to reimburse you for the CPAP machine (E0601) and nasal mask (A7034). You say that given weather conditions and COVID restrictions you opted to make purchases from internet vendors. The Plan denied your request. The Plan says the supplier is not a participating Medicare provider therefore payment cannot be made.
Medicare rules say that for equipment to be covered it must be purchased from a Medicare certified supplier. Medicare will only cover your durable medical equipment (DME) if your DME supplier is enrolled in Medicare.
Suppliers have to meet strict standards to enroll and stay enrolled in Medicare. This supplier is not contracted with Medicare. Therefore, we decided that the Plan does not have to reimburse you for the CPAP machine and nasal mask purchased on March 18, 2021 from a non-certified provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 1, 2021.
You asked the Plan to pay for the dental service. You say that you went to a specialist. You say that the specialist did not do the procedure correctly. You say that you were referred to an oral surgeon. You also say that in order to get service from the surgeon, you needed an oral evaluation. The Plan denied your request. The Plan says 1 limited oral evaluation per plan year. The Plan also says that the frequency limit has been exceeded.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage and the service is listed as covered, the frequency limit has been exceeded. The record shows that the Plan paid for a limited oral evaluation that you received on March 30, 2021. Therefore, we decided that the Plan does not have to pay for the limited oral evaluation (D0140) provided on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copay for the office visit provided on June 1, 2021.
You asked the Plan to waive the copay for the office visit. You say that you visited your physician for your
annual physical. The Plan denied your request. The Plan says the claim processed correctly.
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 $20
copay for services at a primary care office.
The file shows that you were billed for an office visit and not an annual physical. You have been asked to pay a
$20 copay for the office visit. The visit falls within the physician services 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 copay for the office visit provided on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the oncology services provided on February 17, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the services provided. You say that you have been seeing this physician for 6 years. The Plan denied your request. The Plan says the services were not authorized.
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 provider in this case is not a network provider with the Plan. The Plan had network providers available
who could have provided the services at issue in this appeal. The Plan did not pre-approve the services at issue.
We found no exception that would require the Plan to pay for these services. Therefore, we decided that the
Plan does not have to pay for the oncology services provided on February 17, 2021 by an out-of-network
(OON) provider.