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

We decided that the Plan does not have to pre-approve the Inspan procedure for the enrollee.

You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of the Inspan procedure in the setting of lumbar spinal stenosis has not been demonstrated in the peer-reviewed literature.

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 requested services are not considered medically reasonable and necessary in this case. The Inspan procedure is experimental. More research is needed to show safety and efficacy. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services. 

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 the Inspan procedure for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option and accessories.

You asked the Plan to pre-approve Group 3 power wheelchair with single power option. You say that this is absolutely necessary for you to live safely and independently. The Plan denied your request. The Plan says the denial of authorization for this device is correct, because you do not meet criteria for a Group 3 power wheelchair with single power option and may instead use a Group 3 power wheelchair with no power options.

The Plan follows Medicare rules. Medicare rules state that a Group 3 power wheelchair with single power option may be covered by Medicare if the enrollee meets the clinical criteria described in the previous 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 Group 3 power wheelchair with single power option. Our reviewer says that you do not meet the Medicare criteria for the requested Group 3 power wheelchair with single power option. Our physician reviewer found the records do not document that you meet criteria for a power tilt feature; no records document you have high risk for development of a pressure ulcer and are unable to perform a functional weight shift, that you utilize intermittent catheterization for bladder management and are unable to independently transfer from the wheelchair to the bed, or that the power seating system is needed to manage increased tone or spasticity. As you do not meet criteria for power tile, the requested power option is not allowed. You appear to meet criteria for a Group 3 power wheelchair with no power options instead.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Group 3 power wheelchair with single power option have not been met. Because the base power wheelchair is not covered, the requested related accessories are also denied. Therefore, we decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option and accessories.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99100) provided on February 15, 2021.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled services.

The Plan must follow Medicare rules. Medicare rules say that a status indicator of "B" under the Physician Fee Schedule indicates that payment for covered services are always bundled into payment for other services not specified. 

We looked at the file and Medicare rules. Procedure code 99100 is assigned a status indicator of "B" under the Physician Fee Schedule, which means that this is a bundled service. Payment for this service is bundled into payment for other services. No separate payment can be made for the anesthesia services (99100). 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 (99100) provided on February 15, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an outpatient surgery provided by a participating provider on March 1, 2021.

You asked the Plan to waive the copayment for an outpatient surgery. You say that you disagree with this copayment. The Plan denied your request. The Plan says the correct copayment has been applied.

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 $225 copayment for outpatient surgery. 

You have been asked to pay a $225 copayment for an outpatient surgery. An outpatient surgery 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 an outpatient surgery provided by a participating provider on March 1, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve 8 outpatient physical therapy (PT) visits.

You asked the Plan to pre-approve 8 PT visits. You say that the requested services are medically necessary for hip pain. The Plan denied your request. The Plan says the additional visits are not medically necessary.

The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.

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 8 PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found there is no documentation that the specialized skill, knowledge and judgment of a qualified therapist is required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration. The reviewer found that the available records indicate that after 24 physical therapy treatments, you appear to have improved with therapy, you have met your short term goals, and you are progressing towards your long term goals. Therefore, the reviewer found that the 8 PT visits are not medically reasonable or necessary.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 8 PT visits have not been met. Specifically, the file shows that you have improved with therapy and have met your goals with the 24 PT visits that you have already received. Therefore, we decided that the Plan does not have to pre-approve 8 outpatient physical therapy (PT) visits.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for power wheelchair repair services provided on July 14, 2021, by an out-of-network provider.  You asked the Plan to pay for power wheelchair repair services. You say that the services at issue were a dire need for you. The Plan denied your request. The Plan says rules for out-of-network care have not been met.  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 power wheelchair repair services provided on July 14, 2021, by an out-of-network provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for dialysis services provided to the enrollee from March 26, 2021, to March 29, 2021. You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the codes were not reported properly. 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 the denied codes is: CPT 90999: Unlisted dialysis procedure, inpatient or outpatient  Healthcare Common Procedure Coding System (HCPCS) J2916: Injection, sodium ferric gluconate complex in sucrose injection, 12.5 mg  HCPCS J2997: Injection, alteplase recombinant, 1 mg  We find that CPT code 90999 is not supported in the medical record. Specifically, this code has a status indicator of "B." This means that this code cannot be paid for separately, and is always bundled into payment for other services not specified. We find that HCPCS J2997 is not supported in the records. Specifically, this code has a status indicator of "K." These codes cannot be paid separately without a covered primary code. CPT 90990 is not covered in this case, so J2997 also cannot be covered. We find that HCPCS J2916 is not supported in the medical records. Specifically, this code has a status indicator of "N" which means that payment for this code is bundled. 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 dialysis services provided to the enrollee from March 26, 2021, to March 29, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayments for wound debridement services you received at an outpatient hospital facility from July 6, 2021, to July 26, 2021.  You asked the Plan to waive the copayments for the wound debridement services. You say that you should not have to pay a separate facility copayment for these services. The Plan denied your request. The Plan says you were charged these copayments 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 $200 copayment per visit for outpatient surgery and other services at an outpatient hospital services.   You have been asked to pay a $200 copayment per visit for the wound debridement services. The wound debridement services fall within the outpatient surgery and other services at an outpatient hospital 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 copayments for wound debridement services you received at an outpatient hospital facility from July 6, 2021, to July 26, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay an additional amount for inpatient hospital care provided from April 7, 2021, to April 14, 2021.  You asked the Plan to pay an additional amount for the inpatient care. You say that the provided documentation clearly supports the billing of original coding. The Plan denied your request. The Plan says the documents submitted do not support the principal and secondary diagnoses.  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 principal diagnosis code, T82.7XXA, defined as infection and inflammatory reaction due to other cardiac and vascular devices, implants and grafts, initial encounter, and secondary diagnosis code, I50.20, defined as unspecified systolic (congestive) heart failure. 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 an additional amount for the inpatient care. Our physician reviewer found the billing of the principal or secondary diagnosis codes are not supported by the provided documentation.   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 an additional amount for inpatient hospital care provided from April 7, 2021, to April 14, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve revision arthroplasty (23473, 23474) and hemiarthroplasty (23470) for the enrollee.  You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the denial of revision arthroplasty and hemiarthroplasty was appropriate given the clinical scenario and the guidance.  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 requested services are not considered medically reasonable and necessary in this case. The enrollee is being treated for primary osteoarthritis of the right shoulder. The enrollee presented with persistent right glenohumeral joint anteriorly. There is no lateral upper arm pain on the right.  Exam reveals right shoulder point tenderness of the glenohumeral joint. Active range of motion is forward elevation of 90, external rotation of 50, and internal rotation of 0. There is crepitus with range of motion. Supraspinatus strength is 5-/5 on the right. There is a noted approval of an anatomical right total shoulder arthroplasty. However, detailed documentation is not evident regarding a need for a revision procedure when the primary procedure has not yet been completed. Our physician reviewer found that the enrollee's condition does not meet criteria for coverage of these services.  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 revision arthroplasty (23473, 23474) and hemiarthroplasty (23470) for the enrollee.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that you are appealing with supporting records. The Plan denied your request. The Plan says that the denial of authorization for SNF care is correct.  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 the enrollee meets the Medicare criteria for SNF care. Our physician reviewer found the enrollee does not have daily skilled nursing needs that require the specialized skill, knowledge, and judgment of a skilled professional nurse. However, the enrollee does have daily skilled therapy needs. The enrollee is functioning below her baseline and the documentation does not yet show that the enrollee has reached a plateau in function. Daily skilled therapy services are needed to establish a maintenance program or to prevent deterioration of the enrollee's condition.  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 been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.   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 pay for the critical care services rendered on April 3, 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 procedure code 99291 is not supported.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.  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, there is no documentation of 30-74 minutes of critical care time. 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 critical care services rendered on April 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to provide additional payment for the amalgam - one surface, primary or permanent (D2140) for tooth 19 provided November 19, 2020.  You asked the Plan to provide additional payment for the filling. You say that you would like this claim processed and covered. The Plan denied your request. The Plan says this claim has already been processed and paid correctly.  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. The Plan covers two fillings per calendar year with 50% coinsurance when provided in-network.  We looked at the file and Medicare rules. The Plan provided documentation showing that the Plan covered 50% of the cost of the filling for tooth 19 for the date of service November 19, 2020. This claim covering the filling for tooth 19 was processed on June 17, 2021. Therefore, we decided that the Plan does not have to provide additional payment for the amalgam - one surface, primary or permanent (D2140) for tooth 19 provided November 19, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Minuteman procedure (22612).  You asked the Plan to pre-approve a Minuteman procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this is experimental.  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 a Minuteman procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this is considered an experimental 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 Minuteman procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve a Minuteman procedure (22612).
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an x-ray (71045) provided on February 21, 2021.  You asked the Plan to pay for an x-ray. You say that this is supported in the records. The Plan denied your request. The Plan says this is 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 71045 is a column II code to column I code 99291. This claim has not been billed with an appropriate modifier to bypass the edit. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray (71045) provided on February 21, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services rendered on August 4, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not covered.  The Plan must follow Medicare rules. The rules say that Multiplex PCR respiratory viral panels of 6 or more pathogens are non-covered.  We looked at the file and Medicare rules. The file shows that the services at issue are a respiratory panel of 6 or more pathogens. 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 laboratory services rendered on August 4, 2021.