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

We decided that the Plan does not have to pay for a pneumatic compression device (E0675), provided on
November 12, 2021.
You asked the Plan to pay for a pneumatic compression device. You say that the item was medically necessary.
The Plan denied your request. The Plan says this device is not covered by Medicare to prevent deep vein
thrombosis during and/or following surgery.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement.
We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan.
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to
pay for a pneumatic compression device (E0675), provided on November 12, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the non-emergent ambulance transportation (A0428) and mileage (A0425 and A0888), provided on July 26, 2021.
You asked the Plan to pay for the ambulance transport and mileage. You say that the service was medically necessary. The Plan denied your request. The Plan says your request is not medically necessary because the records show you were at a hospital with appropriate facilities for your needs and transportation was for patient preference not medical necessity.
Medicare pays for ambulance services only when they are medically reasonable and necessary. The Plan follows the same rules. Patient transported from one hospital to another hospital is covered only if the hospital to which the patient is transferred is the nearest one with appropriate facilities. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the ambulance transport and mileage have not been met. Therefore, we decided that the Plan does not have to pay for the non-emergent ambulance transportation (A0428) and mileage (A0425 and A0888), provided on July 26, 2021
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Omniseq testing rendered on August 12, 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 were not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that molecular pathology testing is 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 pay for these services. Our reviewer says that the services were not medically necessary. Our physician reviewer found the records show that you have a diagnosis of squamous cell carcinoma of the vaginal cuff. The submitted documentation does not include results of the Omniseq testing. The documentation does not show that alternative laboratory or clinical tests to definitively diagnose your condition are unavailable or that the number of genes testing was reasonable and medically necessary to obtain information for therapeutic decision making. The documentation is insufficient to demonstrate that the Omniseq testing was medically reasonable and necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pay for the Omniseq testing rendered on August 12, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapy services and vitamin injections provided on
August 5, 2021.
You asked the Plan to pay for the therapy services and vitamin injections. The Plan denied your request. The
Plan says the services are not covered.
The Plan must follow Medicare rules. Medicare rules say that Part B pays for outpatient physical therapy
services only if they are furnished by, or under the direct supervision of a physical therapist in private practice;
or by, or incident to the service of a nurse practitioner (NP) or physician assistant (PA) only when that NP/PA
may perform physical therapy services under State law. Medicare rules say that claims for compounded drugs
shall be submitted using a compounded drug, not otherwise classified (NOC) code.
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for
coverage of the therapy services and vitamin injections have not been met. Specifically, the physical therapy
services at issue in this case were rendered by a nurse practitioner who is not licensed to provide physical
therapy. In addition, the multiple drug codes reported on this claim refer to a pre-filled compounded
drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified
code J7999. As this compounded drug was not billed properly, payment cannot be made. Because the drugs are
not paid as billed, the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan
does not have to pay for the therapy services and vitamin injections provided on August 5,2021
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 your needs cannot be met at a lower level of care. The Plan denied your request. The Plan says under Medicare, the request is not medically necessary.
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 that there is no documentation provided indicating medical necessity for admission to an LTACH. You are receiving appropriate care at the present acute care hospital. You do not require services at the LTACH that are not available at the acute care hospital where you are currently receiving care. There are no services available at the LTACH that you require that are not available at the health care setting being offered by the health plan. The requested LTACH services are not medically necessary, reasonable, and appropriate for your diagnosis and condition and able to be furnished safely and effectively only on an inpatient basis.
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: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that SNF care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested SNF care is not medically reasonable and necessary.
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 the beneficiary is a 75-year-old female with breast cancer who is status post mastectomy. In this case, there are no identifiable skilled nursing service needs and no identifiable skilled therapy service needs. Furthermore, the beneficiary does not require skilled nursing or therapy services on a daily basis. In conclusion, this beneficiary does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 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 admission to a skilled nursing facility (SNF).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the simple repair of superficial wounds (12013) and electrocardiogram services (93010) provided on December 17, 2020.
You asked the Plan to pay for the medical services. You say that you would like these claims reprocessed based on the medical records provided. The Plan denied your request. The Plan says an appropriate modifier was not billed with these claims as required by Medicare rules.
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 codes 12013 and 93010 are column II codes to column I code 21310. 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 the simple repair of superficial wounds (12013) and electrocardiogram services (93010) provided on December 17, 2020
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to an inpatient rehabilitation facility (IRF).
You asked the Plan to pre-approve IRF care. You say that this is medically necessary. The Plan denied your request. The Plan says needs can be met in a lower level of care, such as skilled nursing facility, home with supervision and home health services, in an assisted living facility with home health services or in long-term care with part-time skilled services.
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 weakness and hypothyroidism and was discharged home on 12/7/21. There is ongoing weakness. 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 admission to an inpatient rehabilitation facility (IRF).
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 this is medically necessary. The Plan denied your request. The Plan says the services can be received in other settings, for example: a skilled nursing facility, home with home health services 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 diarrhea and abdominal pain.. 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for an office visit provided to the enrollee on January 14, 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 these codes should not be used.
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 99214:
Office or other outpatient visit for the evaluation and management of an established patient, which requires a
medically appropriate history and/or examination and moderate level of medical decision making. When using
time for code selection, 30-39 minutes of total time is spent on the date of the encounter.
Healthcare Common Procedure Coding System (HCPCS) G0467:
Federally qualified health center (fqhc) visit, established patient; a medically-necessary, face-to-face encounter
(one-on-one) between an established patient and a fqhc practitioner during which time one or more fqhc
services are rendered and includes a typical bundle of medicare-covered services that would be furnished per
diem to a patient receiving a fqhc visit
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 to qualify for Medicare payment, all
the coverage requirements for a federally qualified health center (FQHC) visits must be met. A FQHC visit
must be furnished in accordance with the applicable regulations at 42 CFR Part 405 Subpart X, including 42
CFR 405.2463 that describes what constitutes a visit.
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 an office visit provided to the enrollee on January 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from May 11, 2020, to May 12, 2020, and billed with DRG (diagnosis related group) 208.
You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your request. The Plan says this DRG is not supported.
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 DRG 208, respiratory system diagnosis with ventilator support at least 96 hours. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for inpatient care. Our reviewer says that the billed DRG is not supported. Our physician reviewer found the submitted medical records document an admission for diabetes with hypoglycemia. The documentation is unclear regarding pneumonitis due to inhaled food and vomit. Even though aspiration pneumonia is noted throughout the medical record, supporting documentation was not found. The documentation is inconsistent, and aspiration is referenced in the record with a question mark. The enrollee's lung sounds were noted to be clear to auscultation and percussion bilaterally. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient care provided from May 11, 2020, to May 12, 2020, and billed with DRG (diagnosis related group) 208.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a skilled nursing facility (SNF) admission.
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 admission is not medically necessary.
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 these services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found you were admitted to the hospital on
November 13, 2021 with pneumonia and discharged to the SNF on November 19, 2021. You have no
documented skilled nursing or skilled therapy needs. You are at your functional baseline. You do not require
skilled nursing or skilled therapy on a daily basis. As a practical matter, you do not require the necessary
services on an inpatient basis at the SNF level of care.
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 skilled nursing facility (SNF) admission.
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 these services are medically necessary. The Plan denied your request. The Plan says that the member is receiving appropriate in-patient acute care and does not require 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 he 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 radiology services (procedure codes 77063, 77067) provided
to the enrollee on July 30, 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 these services were denied as duplicate services.
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 77063:
Screening digital breast tomosynthesis, bilateral (List separately in addition to code for primary procedure)
CPT 77067:
Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD)
when performed
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 medical records submitted do not
support billing CPT 77063 or 77607 twice. CPT 77063 and 77067 are bilateral codes and were previously paid
on claim # 820212181356534 on check/remit #000221395. Therefore these codes are not eligible for separate
reimbursement.
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 radiology services (procedure codes 77063, 77067) provided to the enrollee on July 30, 2021.