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

We decided that the Plan does not have to pay for the services (70450) provided on November 30, 2020.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled service.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that code 70450 has a bundled relationship with code 70496 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for the services (70450) provided on November 30, 2020.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic exercises (97110) provided on April 16, 2021.
You asked the Plan to pay for the therapeutic exercises (97110). You say that you included the medical records, appeal request, Waiver of Liability so the claims can be reprocessed. The Plan denied your request. The Plan says an appropriate modifier was not billed with this code edit.
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 97110 has a bundled relationship with code 92526 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 therapeutic exercises (97110) provided on April 16, 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 mobility will not improve at the current level of treatment. The Plan denied your request. The Plan says an intensive rehabilitation program is not medically necessary.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for surgical repair of a hip fracture after a fall. 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 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 you 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 pay for the debridement services provided on April 26, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the debridement services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services rendered 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 debridement services provided on April 26, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the eye exam and related services provided on November 11, 2020 by an out-of-network (OON) provider.

You asked the Plan to pay for the eye exam and related services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services provided are not a covered benefit.

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 eye exam and related services provided on November 11, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the anesthesia services provided for a non-invasive imaging service on November 15, 2020 with code 01922.
You asked the Plan to pay for the anesthesia services as billed. You say that there are no bundling issues between these two codes so both should be paid in full. The Plan denied your request. The Plan says this was not billed correctly for anesthesia services provided for multiple procedures.
The Plan must follow Medicare rules. Medicare rules say that physicians bill for the anesthesia services associated with multiple/bilateral surgeries by reporting the anesthesia procedure with the highest base unit value with the multiple procedure modifier -51. They report the total time for all procedures in the line item with the highest base unit value.
In this case, the rendering provider furnished anesthesia services for a spinal surgery during the same operative session on this patient. This was paid on another claim under code 00620 for 236 minutes. The claim at issue in this case is for 01922 for 38 minutes. Code 00620 has 10 base units, and 01922 has 7 base units. As such, the correct way to bill for these services would be to report code 00620 with modifier -51 and include all the time spent for both procedures on this line item, 274 minutes in this case. Since these were billed on separate claims and modifier -51 was not reported on the higher base-unit code, denial of payment for this second code, 01922, is appropriate. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided for a non-invasive imaging service on November 15, 2020 with code 01922.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve F5 gene (coagulation factor V) genetic testing.

You asked the Plan to pre-approve F5 gene (coagulation factor V) genetic testing. You say that you would like
the Plan to reconsider their denial. The Plan denied your request. The Plan says the requested genetic testing is
considered 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 looked at the file and Medicare rules. Medicare says F5 gene testing is not considered to be clinically
efficacious and is not medically necessary. Therefore, we decided that the Plan does not have to pre-approve F5
gene (coagulation factor V) genetic testing.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for physician services (99335) provided on September 15, 2020 by an out-of-network (OON) provider.
You asked the Plan to pay for the physician services. You say that the services were medically necessary. The Plan denied your request. The Plan says there were network providers available.
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 services at issue in this appeal. The Plan did not pre-approve the service 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 physician services (99335) provided on September 15, 2020 by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy procedure
(0275T).
You asked the Plan to pre-approve a percutaneous laminotomy/laminectomy. You say that this is medically
necessary. The Plan denied your request. The Plan says the coverage criteria have not been met.
The Plan follows Medicare rules. Medicare rules say that PILD will be covered when provided in a clinical
study
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 a percutaneous
laminotomy/laminectomy. Our reviewer says that the requested procedure is not medically reasonable and
necessary. Our physician reviewer found percutaneous laminectomy remains experimental for treatment of
lumbar disc problems. More research is needed to show safety and efficacy of the procedure.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a percutaneous laminotomy/laminectomy have not been met. Therefore, we
decided that the Plan does not have to pre-approve a percutaneous laminotomy/laminectomy procedure
(0275T).
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
You asked the Plan to pre-approve SNF care. 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. The rules say that Medicare pays for care in a SNF when the four factors listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve SNF care. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found documentation does not support the need for your continued stay in an SNF due to lack of documented daily progress and the wound care is chronic. Your care needs can be safely provided at an alternate and lower intensity setting such as in a long-term care (LTC) facility. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have not been met. Therefore, we decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for digital breast tomosynthesis (G0279) provided on August 18, 2020.
You asked the Plan to pay for digital breast tomosynthesis. You say that this is supported in the records. The Plan denied your request. The Plan says this was not billed with an appropriate primary code.
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 G0279 is diagnostic digital breast tomosynthesis, unilateral or bilateral (list separately in addition to 77065 or 77066).
We find that CPT code G0279 is not supported in the medical record. Specifically, this should be billed with
77065 or 77066, which were not present on the claim. Based on this information, we decided that Medicare
rules for coverage of digital breast tomosynthesis have not been met. Therefore, we decided that the Plan does
not have to pay for digital breast tomosynthesis (G0279) provided on August 18, 2020.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the biopsy procedure provided on April 15, 2021.

You asked the Plan to waive the copayment for the biopsy procedure. You say that you feel you should not be responsible for this cost share amount and you would like the Plan to reconsider your request. The Plan denied your request. The Plan says you received a surgical procedure in an outpatient hospital setting on the date of service at issue in this appeal. The Plan says that the correct copayment has applied per your contract with the Plan.

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 $100 copayment for Outpatient Surgery.

We looked at the file, the Plan's contract and Medicare rules. The file shows that you received a biopsy procedure on April 15, 2021 provided in an outpatient hospital setting. You have been asked to pay a $100 copayment for the biopsy procedure. The biopsy procedure 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 waive the copayment for the biopsy procedure provided on April 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.

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 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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the enrollee has lumbar spinal stenosis. The requested Superion spacer is considered experimental in nature, as more research is needed to show safety and efficacy. 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 a Vertiflex Superion spacer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the requested admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to an LTACH does not meet criteria.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. 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 LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation of multiple unsuccessful weaning attempts. There are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan.
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 LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for the kidney stone treatment and other outpatient hospital services provided from May 5, 2021, to May 6, 2021.
You asked the Plan to pay for the outpatient hospital services. You say that the codes on this claim are payable, including 50081 which is paid through a composite Ambulatory Payment Classification (APC) group. The Plan denied your request. The Plan says that payment is not allowed for this code because under the outpatient prospective payment system, Medicare doesn't recognize this code.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan has not provided any cogent denial rationale in this case. It is noted that there is a code that is not recognized by the outpatient prospective payment system. This situation is denoted by codes with a status indicator of "B". None of the codes billed on this claim have this status. The Plan did not specify which code is felt to be noncovered. We find no obvious defect in the coding on this claim in absence of a clear plan argument. As such, the denial of payment is not supported. Therefore, we decided that the Plan has to pay for the kidney stone treatment and other outpatient hospital services provided from May 5, 2021, to May 6, 2021.
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 anesthesia for repeat injections.
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 repeat injections 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 low back pain. She had previous intra-articular facet injections that produced 40 percent pain relief. She did not achieve the required percentage of pain relief required by the Medicare criteria; therefore, the repeat injections are 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 anesthesia for repeat injections.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care
after September 16, 2021.
You asked the Plan to pre-approve the continuation of SNF care. You say that SNF care continues to be
medically necessary. The Plan denied your request. The Plan says rules for SNF care are no longer met.
The Plan must follow Medicare rules. The rules say that Medicare pays for care in a SNF when the four factors
listed in the Medicare rules section are met. Custodial care is not covered.
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to
determine if the Plan was correct in denying the request to pre-approve the continuation of SNF care. Our
reviewer says that daily skilled services are not necessary. Our physician reviewer found you are an 82-yearold
female who is requesting continued SNF services. You were admitted to a SNF on August 25, 2021, after
initially being hospitalized after left hip fracture and subsequent surgery. In this case, you were stable
medically with no functional progress after 2 weeks of daily therapies and did not need any nursing care other
than routine care. The submitted documentation does not support the need for your continued stay in an SNF
with daily skilled therapies in a patient setting. You are not meeting the expectation of making significant
progress in a reasonable period of time. Additionally, there is no carry over of learned skills in therapies with
dementia. Your care needs can be safely provided at an alternate and lower intensity setting such as in a longterm
care facility.
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 continuation of SNF care have not been met. Therefore, we decided that the
Plan does not have to pre-approve the continuation of skilled nursing facility (SNF) care after September 16,
2021.