Persius/hicric huggingface dataset:
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for supplies provided to the enrollee on June 3, 2020.
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 provider did not bill as required by Medicare coding regulations.
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 A4556 is "Electrodes, (e.g., apnea monitor), per pair." We find that CPT code A4556 is not supported in the medical record. Specifically, this code has a status indicator of "P." This means that no separate payment is allowed for this code. 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 supplies provided to the enrollee on June 3, 2020.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for radiologic examination, abdomen (74018) provided August 23, 2021.

You asked the Plan to pay for the diagnostic service. You say that the procedure was rendered in an appropriate place of service. Please review and reconsider the claim for payment. The Plan denied your request. The Plan says the claim has missing/incomplete/invalid/inappropriate place of 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 find that CPT code 74018 is not supported in the medical record. Specifically, the claims history show that the enrollee was inpatient during this date of service. The claim was billed with an inappropriate place of service of 22 (outpatient hospital). Based on this information, we decided that Medicare rules for coverage of the diagnostic service have not been met. Therefore, we decided that the Plan does not have to pay for radiologic examination, abdomen (74018) provided August 23, 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 based on IRF criteria. The Plan states you could
receive care in another setting, and they could review alternate settings if requested such as skilled nursing
facility, outpatient setting or home health 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 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for observation care discharge day management services (procedure code 99217) provided to the enrollee on June 25, 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 it is not appropriate to bill this code on the same day.

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 99217 is "Observation care discharge day management (This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital "observation status" if the discharge is on other than the initial date of "observation status." To report services to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.])." 

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 services. Our reviewer says that the services at issue in
this case were not supported by the medical records. Our reviewer found the documentation supports two observation care encounters. The enrollee was seen in the emergency department, and admitted for observation care on June 25, 2021 at 22:41, and then observation discharge provided on June 26, 2021 at 10:19. However, both encounters were reported with date of service June 25, 2021. Therefore this service was reported incorrectly, as the discharge was performed on June 26, 2021. 

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 services have not been met. Therefore, we decided that the Plan does not have to pay for observation care discharge day management services (procedure code 99217) provided to the enrollee on June 25, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for ambulance transport you received on September 21, 2021.

You asked the Plan to waive the copayment for the ambulance transport. You say that you were advised you needed to go to another hospital for a scan. You were transported via helicopter part of the way. You were then transferred to a ground ambulance for the remainder of the trip to the hospital. You say that the helicopter should have been able to take you all the way to the hospital, so you should only have to pay one of the transportation copayments. The Plan denied your request. The Plan says two separate ambulance transport services were provided, so two copayments apply.

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 $325 copayment per trip for ambulance services.

You have been asked to pay a $325 copayment per trip for the ambulance transport. You used two different modes of transportation, provided by two different ambulance companies. Your copayment is assessed on a per-trip basis. Because you had two separate and distinct transports to get to your destination, two separate copayments apply. 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 ambulance transport you received on September 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on April 21, 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 testing is not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, fluoresence in-situ hybridization (FISH) testing, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on April 21, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for pathology services (36415, 80053, 80061, 81001, 82306, 82607, 82746, 83036, 84443, 85025, P9604) provided on August 31, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for pathology services. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this provider is not a network provider with the Plan and the services were not referred by a network provider or rendered in an in-network facility. The Plan also says that they have also determined that these services were not urgent or emergent, nor were they approved in advance.

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 pathology services (36415, 80053, 80061, 81001, 82306, 82607, 82746, 83036, 84443, 85025, P9604) provided on August 31, 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 critical care services (99291) provided on December 15, 2020.

You asked the Plan to pay for the services. The Plan denied your request. The Plan says the billed services are 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, the records provided do not show that 30-74 minutes of critical care services were provided on the date of service in question. 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 critical care services (99291) provided on December 15, 2020.
Appeal type: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pre-approve attendant care services; per 15 minutes (CPT code
S5125), homemaker service, nos; per 15 minutes (CPT code S5130), and personal care services, per diem, not
for an inpatient or resident of a hospital, nursing facility, icf/mr or imd, part of the individualized plan of
treatment (code may not be used to identify services provided by home health aide or certified nurse assistant)
(CPT code T1020), for the enrollee.

You asked the Plan to pre-approve the services. You say that the services are necessary. The Plan denied your
request. The Plan says the requirement is: home health aide services must be provided along with skilled care
(skilled nursing, physical, occupational or speech therapy). The Plan states the home health aide services you
asked for are not being done for medical reasons or helping with skilled nursing or therapy care.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

CPT code(s): T1020, S5125, and S5130, have a status code of "I". Medicare guidance says status code "I" Not
valid for Medicare purposes. Medicare uses another code for reporting of and payment for these services.

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 pre-approve attendant care services; per 15 minutes (CPT code S5125), homemaker service, nos; per 15 minutes (CPT code S5130), and personal care services, per diem, not for an inpatient or resident of a hospital, nursing facility, icf/mr or imd, part of the individualized plan of treatment (code may not be used to identify services provided by home health aide or certified nurse assistant) (CPT code T1020), for the enrollee.
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 had a mini-stroke and the case you need is only available through rehabilitation. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states your records show that you do not require supervision of a rehabilitation doctor at least three (3) times per week and you do not require aggressive therapies by an intensive team in order to properly regain your function. 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, or home with outpatient 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 a stroke. 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: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services for the enrollee.

You asked the Plan to pre-approve the LTACH services. You say that the enrollee cannot be optimally restored at any other level of care. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and is currently unstable for transfer to an LTACH.

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. The enrollee is receiving appropriate care at the present acute care hospital. The enrollee does not require services at the LTACH that are not available at the acute care hospital where she is currently receiving care.

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. Our physician reviewer found that the enrollee's condition does not meet Medicare criteria for LTACH 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 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 for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for imaging services provided to the enrollee on September 19, 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 this service should not be unbundled.

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 70544 is a column II code to column I code 70551. 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 imaging services provided to the enrollee on September 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for therapeutic radiology treatment management (77300) provided on April 8, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the outpatient services. You say that attached with this request are all applicable medical records. Please review and reconsider this claim The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.

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 therapeutic radiology treatment management (77300) provided on April 8, 2021 by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the magnetic resonance imaging (MRI) of the spine you had on September 10, 2021.

You asked the Plan to waive the copayment for the MRI. You say that you thought that your insurance would cover the total cost of this MRI. The Plan denied your request. The Plan says you were charged this copayment correctly. The Plan says that because the allowed amount for this MRI ($212.50) is less than your copayment obligation, you are responsible for the full allowed amount.

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 $320 copayment for advanced imaging services. 

You have been asked to pay a $320 copayment for the MRI. The MRI falls within the advanced imaging 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 copayment for the magnetic resonance imaging (MRI) of the spine you had on September 10, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve mitral valve replacement.
You asked the Plan to pre-approve mitral valve replacement. You say that the requested service is medically
necessary. The Plan denied your request. The Plan says there is no documentation of aortic valve disease;
therefore, the requested service 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 pre-approve mitral valve replacement. Our reviewer
says that the requested service is not considered medically reasonable and necessary in this case. Our physician
reviewer found that echocardiography assessed the mitral regurgitation as less than severe, while the left
ventricle (LV) was not dilated, and LV function was described as normal. As such, the documentation would
not suggest that the mitral regurgitation is of sufficient severity to warrant valve replacement
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of mitral valve replacement have not been met. Therefore, we decided that the
Plan does not have to pre-approve mitral valve replacement.