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

We decided that the Plan does not have to pay for laboratory testing provided on February 3, 2021.

You asked the Plan to pay for lab tests. You say that at this time there is no contractual agreement in place which indicates that these codes are included in the dialysis rate. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because lab services related to the treatment of end stage renal disease (ESRD) are included in the payment made to the dialysis center.

The Plan must follow Medicare rules. Medicare rules say that lab services related to ESRD and included in the ESRD prospective payment system base rate paid to the dialysis facility. Services that are not related to ESRD must be billed with the -AY modifier. 

We looked at the file and Medicare rules. The record shows that these lab services were related to ESRD; therefore, they are included in the ESRD prospective payment system base rate and are not separately paid. Based on this information, we decided that Medicare rules for coverage of lab tests have not been met. Therefore, we decided that the Plan does not have to pay for laboratory testing provided on February 3, 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 your records received do not indicate you need nor can tolerate an intensive therapy program with multiple visits from a rehabilitation doctor per week. The Plan states you can safely receive the services you need in other settings, for example: a skilled nursing facility, home with home health and home physical therapy.
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 pneumonia and atrial fibrillation with rapid ventricular response. 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. 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 services (34812) provided on May 12, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the MUE was exceeded.

The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. 

In this case, the MUE for CPT code 34812 is 1. The MAI value for this code is 2. You billed 2 units of this code, exceeding the MUE. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for the services (34812) provided on May 12, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for mechanical traction (97012) vasopneumatic devices (97016)
and outpatient office visit (99213) provided January 5, 2021 to January 19, 2021.

You asked the Plan to pay for the chiropractic services. You say that you have massage therapy benefits, and
the services should be covered. The Plan denied your request. The Plan says these services are not covered
when rendered 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 service at issue is not manual manipulation of the spine. Therefore, we decided that
the Plan does not have to pay for mechanical traction (97012) vasopneumatic devices (97016) and outpatient
office visit (99213) provided January 5, 2021 to January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient consultation (99254) provided on April 21, 2021.

You asked the Plan to pay for the inpatient consultation. You say that you would like reconsideration because
this consultation resulted in the decision for surgery. The Plan denied your request. The Plan says this is not a
Medicare covered benefit.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

We find that CPT code 99254 is not supported in the record. Specifically, CPT code 99254 has a status
indicator of I. This means that CPT code 99254 is not valid for Medicare purposes. Based on this information,
we decided that Medicare rules for coverage of the inpatient consultation have not been met. Therefore, we
decided that the Plan does not have to pay for the inpatient consultation (99254) provided on April 21, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from March 1,
2020, to March 16, 2020, and billed with code CAGE1.
You asked the Plan to pay for SNF care. You say that this was billed correctly. The Plan denied your request.
The Plan says there is not documentation that the enrollee was diagnosed with malnutrition.
The Plan must follow Medicare rules. Medicare rules say that SNF services are paid under the SNF PDPM
PPS. Under this system, each digit of the HIPPS code corresponds to a different case-mix group aspect of the
SNF care provided.
We looked at the file and Medicare rules. Based on the PDPM calculations worksheet and the conditions
reported by the SNF, the billed HIPPS code is not correct. While the enrollee was stated to be "at risk" for
malnutrition, the records and diagnoses billed do not show that the enrollee had an active diagnosis of a
malnutrition code. A risk of malnutrition is not listed as an NTA-related comorbidity. 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 pay for skilled nursing facility (SNF) care provided from March 1, 2020,
to March 16, 2020, and billed with code CAGE1.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care from December 16, 2021, forward.
You asked the Plan to pre-approve continuation of inpatient mental health care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the request is not medically necessary because the records received show that your condition has improved, and you are no longer a threat to yourself or others.
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 pre-approve continuation of inpatient mental health care. Our physician reviewer found you do not meet the criteria for treatment in an acute inpatient mental health treatment beyond the date in question of December 16, 2021, forward, and could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations and was not showing any aggressive behaviors while being cooperative and compliant. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of continuation of inpatient mental health care have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of inpatient mental health care from December 16, 2021, forward
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 LTACH is medically necessary and the best setting for the enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH would add no additional services. With additional time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.
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 the enrollee appears to be improving and weaning appropriately and should only require short-term additional acute care services that the enrollee can receive safely at the current facility. The enrollee does not require services at the LTACH that are not already available and covered at the current facility. Transfer to the LTACH will be considered not medically necessary as it would not be clinically advantageous. Transfer to a lower level of care should be appropriate soon when treatment has completed.
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: Practitioner Services
Decision: Partially Favorable

We decided that the Plan has to waive the copayment for the specialist office visit. We decided that the Plan
does not have to waive the coinsurance for the outpatient laboratory services.

You asked the Plan to waive the copayment for the office visit. You say that the correct cost-sharing should be
a 10% coinsurance for outpatient lab services per your contract with the Plan. The Plan says that the cost
sharing applied correctly based on the services rendered.

We decided that the Plan has to waive the copayment for the specialist office visit.

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 says that you must pay a $50
copayment for a specialist office visit. The plan has not given sufficient evidence to support their claims that
this visit would fall under the specialist office visit category and that you are subject to a $50 copayment. It is
not known from the documentation if the practitioner seen is working under a specialist.

We also decided that the Plan does not have to waive the copayment for outpatient laboratory services.

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 10%
coinsurance for outpatient laboratory services. The allowed amount is $69.96, 10% of that is $7.

Therefore, we decided that the Plan does not have to waive the coinsurance for outpatient laboratory services
and your copayment of $50 will be reduced to a $7 cost-sharing.

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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital outpatient clinic visit for assessment and management of a patient (G0463) provided on December 29, 2020, by an out-of-network (OON) provider.

You asked the Plan to pay for the outpatient service. You say that the service was medically necessary. The Plan denied your request. The Plan says prior authorization was not obtained before the services were rendered to the enrollee. The Plan also says that the services rendered were not urgent or emergent in nature.

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 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 hospital outpatient clinic visit for assessment and management of a patient (G0463) provided on December 29, 2020, by an out-of-network (OON) provider.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the dental services provided on August 11, 2021.

You asked the Plan to pay for the dental services. You say that this was a routine exam and cleaning. You say
that you had the appointment with this dentist six months ago and it should be paid. The Plan denied your
request. The Plan says services obtained from vendors outside the network are not covered.

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, out-of-network dental services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the dental
services provided on August 11, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for chemotherapy administration (96402), and urinalysis, by dip
stick (81000, J9217) provided on May 20, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for chemotherapy administration, and urinalysis, by dip stick. You say that the
enrollee only provided his traditional Medicare number, which is why an authorization was not obtained. The
Plan denied your request. The Plan says The services provided require prior authorization. No authorization has
been obtained.

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 chemotherapy administration (96402), and
urinalysis, by dip stick (81000, J9217) provided on May 20, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve physical therapy services for lymphedema treatment to be provided by an out-of-network provider.
You asked the Plan to pre-approve the out-of-network services. You say that you are requesting review of denial of services. The Plan denied your request. The Plan says there are in-network provider that can provide the services.
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 physical therapy services for lymphedema treatment to be provided by an out-of-network provider
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy services (90837) provided June 29, 2021.

You asked the Plan to pay for the psychotherapy services. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says there was no documentation of the required consultation with the attending or primary care physician in the enrollee's medical record.

The Plan must follow Medicare rules. Medicare rules say that the provider must attempt to consult the attending or primary care physician about the services furnished and document consent or declination date to consultations and date of consultations in patient's medical record. If consultations are unsuccessful, document the patient's medical chart with the date and physician notification method. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for individual psychotherapy services (90837) provided June 29, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on October 1, 2021.

You asked the Plan to pay an additional amount for eyeglasses. The Plan denied your request. The Plan says the claim processed correctly.  

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.

We looked at the file and the Plan's rules. The file shows the claim processed with the correct allowance for the supplemental eyewear. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on October 1, 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 you need the rehabilitation to help you because you need assistance with bathing or using the restroom and you need someone at all times. You state you think that rehabilitation will help you. 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 your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You are living at home and have a past medical history including hypertension, vascular dementia and are having frequent falls at
home. 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. 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: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Granix (J1447).
You asked the Plan to pre-approve Granix. You say that this is medically necessary. The Plan denied your request. The Plan says this use is not supported.
The Plan must follow Medicare rules. The rules say that Medicare may pay for unlabeled uses for FDA-approved 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 Granix. Our reviewer says that the requested use of Granix is not supported. Our physician reviewer found the requested use of Granix is not FDA-approved for the enrollee's diagnosis. Its use is not supported by one of the major drug compendia or by clinical research that appears in a CMS-approved medical journal. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Granix have not been met. Therefore, we decided that the Plan does not have to pre-approve Granix (J1447).