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

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life
support, emergency transport, level 1 (A0427) and ground mileage, per statute mile (A0425) provided April 17,
2021.
You asked the Plan to waive the copayment for the ambulance transport. You say that you were offered a ride
in the ambulance as a passenger and should not be charged as a patient. The Plan denied your request. The Plan
says the copayment was applied 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 $290
copayment per date of service for ground ambulance.
You have been asked to pay a $290 copayment for the ambulance transport. This service falls within the
Ambulance services benefit category. The record shows that the non-contracted provider billed for an
emergency transport. This means that you have been asked to pay the correct amount based on the billing of the
service and 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
ambulance service, advanced life support, emergency transport, level 1 (A0427) and ground mileage, per
statute mile (A0425) provided April 17, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to adjust the copayment for the cataract surgery provided on March 10, 2020.
You asked the Plan to adjust the copayment for extracapsular cataract removal with insertion of intraocular lens prosthesis (66984). You say that the copayment amount is incorrect. The Plan denied your request. The Plan says you were charged this copayment 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 $350 copayment for Outpatient Surgery. You have been asked to pay a $350 copayment for extracapsular cataract removal with insertion of intraocular lens prosthesis (66984). Extracapsular cataract removal with insertion of intraocular lens prosthesis (66984) falls within the Outpatient Surgery 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 adjust the copayment for the cataract surgery provided on March 10, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided by an out-of-network provider on August 5, 2020, to August 19, 2020.

You asked the Plan to pay for inpatient hospital care. You say that these services were medically necessary. The Plan denied your request. The Plan says while sepsis was documented in the record, other provider documentation was unclear and incomplete regarding this condition.

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 A41.9, defined as sepsis and R65.20, defined by severe sepsis. 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 inpatient hospital care. Our reviewer says that the kidney function and hypoxia requiring fluids and oxygen appear to be directly related to the other diagnoses of heart failure and fluid retention, not due to a systemic infection response. Our physician reviewer found there was no signs of severe infection, organ damage related to infection, or other criteria to justify sepsis or severe sepsis as the primary and secondary diagnoses here. 

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 inpatient hospital care provided by an out-of-network provider on August 5, 2020, to August 19, 2020.
Appeal type: Drugs
Decision: Favorable

We decided that the Plan has to pre-approve Keytruda and Doxorubicin for the enrollee.

You asked the Plan to pre-approve Keytruda and Doxorubicin. You say that these drugs are medically necessary for the enrollee. The Plan denied your request. The Plan says that that the clinical value and effectiveness of Keytruda and Doxorubicin has not been demonstrated in the peer-reviewed literature.

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 and Doxorubicin. Our reviewer says that Keytruda and Doxorubicin are medically reasonable and necessary for the enrollee. Keytruda and Doxorubicin are FDA-approved for the enrollee's diagnosis. This is approved for the treatment of high-risk early stage triple-negative breast cancer, in combination with chemotherapy as neoadjuvant therapy, then continued as a single agent as adjuvant therapy following surgery. Patient can be considered triple negative given weekly prothrombin ratio positive at 6% and elevated Ki67. No chemotherapy regimen is specified in guidelines. The requested drugs are safe and effective and otherwise reasonable and necessary for this enrollee. Our physician reviewer found that the enrollee's condition meets criteria for coverage of Keytruda and Doxorubicin. 

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 and Doxorubicin have been met. Therefore, we decided that the Plan has to pre-approve Keytruda and Doxorubicin for the enrollee.

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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve bilateral medial branch blocks (MBBs).

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.

The Plan must follow Medicare rules. Medicare rules say that MBBs are covered when specific criteria are met.

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has chronic lower back pain. Magnetic resonance imaging (MRI) on December 6, 2019 found severe degenerative narrowing and moderate annular bulging at L1 to L2 disc two. The records do not document that the enrollee is not a candidate
for radiofrequency ablation. The criteria for coverage of the MBBs are not met and the services are therefore not reasonable or 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 these services have not been met. Therefore, we decided that the Plan does not have to pre-approve bilateral medial branch blocks (MBBs).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on July 8, 2021.

You asked the Plan to pay for the periodic oral evaluation (D0120). You say that the cleaning was over six months before this cleaning. The Plan denied your request. The Plan says this service was rendered prior to the 6-month frequency limit.

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, you also have a maximum benefit of one periodic oral evaluation every 6 months. The Plan paid for the periodic oral evaluation provided on February 26, 2021, which exhausted your benefit. Therefore, we decided that the Plan does not have to pay for the periodic oral evaluation (D0120) provided on July 8, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for a neurosurgery office visit provided on February 17, 2021.

You asked the Plan to waive the copayment for office visit. You say that this was a pre-surgical visit and you should owe $0 for this visit. The Plan denied your request. The Plan says the copayment amount you are being charged is correct.

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 $45 copayment for in-network specialist office visit.

You have been asked to pay $45 copayment for office visit. Office visit falls within the Physician/Practitioner Services, Including Doctor's Office Visits 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 neurosurgery office visit provided on February 17, 2021.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services (G0156) provided on September 7,
2020, through September 19, 2020.

You asked the Plan to pay for the home health services. You say that you would like reconsideration based on
the records submitted. The Plan denied your request. The Plan says the documentation submitted does not
support the service billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code G0156 is services of home health/hospice aide in home
health or hospice settings, each 15 minutes.

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 home health services. Our reviewer says that CPT codes G0156 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation submitted consists of phone consultations. There is no documentation to support that a health/hospice aide was in the home or hospice setting. There is also no documentation of the amount of time spent rendering these services. 

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 home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services (G0156) provided on September 7, 2020, through September 19, 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 the enrollee will benefit from acute rehab to optimize their level of functioning prior to returning home. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's nursing, medical management and rehabilitation needs can be met at a lower level of care.

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 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. 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 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: 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 transfer to an IRF is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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 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. 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a special anesthesia service (99100) provided on December
3, 2020.

You asked the Plan to pay for anesthesia. You say that you are appealing with supporting records. The Plan
denied your request. The Plan says the denial of payment for this service is correct, because code 99100 is
always bundled for payment and is not separately payable.

The Plan must follow Medicare rules. Medicare rules say that payment for code 99100 is always bundled into
payment for the service to which it is incident.

We looked at the file and Medicare rules. Payment for this code is always bundled and it is not separately
payable. Based on this information, we decided that Medicare rules for coverage of anesthesia have not been
met. Therefore, we decided that the Plan does not have to pay for a special anesthesia service (99100) provided
on December 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the Positron Emission Tomography (PET) scan provided on
April 15, 2021.

You asked the Plan to pay for the PET scan. You say that the enrollee's medical condition proved medical
necessity for the service. The Plan denied your request. The Plan says an appropriate diagnosis code was not
billed.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate code.

We find that CPT code 78815 was billed with diagnosis code C53.9. We looked at the file and the rules. The
billed diagnosis code is not among those indicated for coverage. Based on this information, we decided that
Medicare rules for coverage of the PET scan have not been met. Therefore, we decided that the Plan does not
have to pay for the Positron Emission Tomography (PET) scan provided on April 15, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay 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 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 a fall, gait instability and pneumonia. 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. 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 IRF admission and services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 10, 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 submitted records do not support the billing of code 27475-59.

The Plan must follow Medicare rules. The rules state that providers may bill services with a -59 modifier if the service billed with the modifier indicates a distinct procedural service. 

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 these services Our reviewer says that the submitted records do not support the billing of code 27475-59. Our physician reviewer found billed procedure code 27475 is inclusive to a total knee arthroplasty, as it was performed in the same site on the same day as the primary procedure. Modifier 59 should be used to distinguish a different session or patient encounter, or a different procedure or surgery, or a different anatomical site, or a separate injury. Therefore, this procedure would not be covered separately. 

We looked at this physician's review, the file, and Medicare rules. 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 February 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiofrequency ablation services provided on March 29, 2021.
You asked the Plan to pay for the services provided. You say that the treatment was medically necessary because of the enrollee's condition The Plan denied your request. The Plan says radiofrequency ablation used for sacroiliac joint pain is not medically necessary.
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 provided. Our physician reviewer found that the enrollee has a history of low back/upper buttock pain and left hip pain. The low back/upper buttock is associated with stiffness and spasm, especially in the morning and with prolonged sitting or standing. She is able to walk comfortably for around 3 miles total a day. There is no balance or gait instability. Radiofrequency ablation for the treatment of sacroiliac joint pain is considered experimental and investigational. Therefore, the provided services were not medically reasonable and 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 provided have not been met. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation services provided on March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit (99204) provided on March 30, 2021.

You asked the Plan to pay for an office visit. You say that this was medically necessary. The Plan denied your request. The Plan says this cannot be paid as billed.

The Plan must follow Medicare rules. Medicare rules say that a physician shall not report a separate evaluation and management (E&M) code with "XXX" procedures for the supervision of others performing the procedure or for the interpretation of the procedure. With most "XXX" procedures, the physician may, however, perform a significant and separately identifiable E&M service on the same date of service which may be reported by appending modifier 25 to the E&M code. 

We looked at the file and Medicare rules. The service at issue is an E&M code that was reported with radiology service with a global surgery indicator of "XXX" but was not reported with modifier 25. Based on this information, we decided that Medicare rules for coverage of an office visit have not been met. Therefore, we decided that the Plan does not have to pay for an office visit (99204) provided on March 30, 2021.