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

We decided that the Plan does not have to pay for the medical services coded as 99053 provided on June 25, 2021.
You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed based on the documentation provided. The Plan denied your request. The Plan says this service is not covered according to 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, the CPT Code Manual definition of code 99053 is service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service We find that CPT code 99053 is not supported in the medical record. Specifically, 99053 has a status code "B"
which indicates that payment for covered services are always bundled into payment for other services not specified. Based on this information, we decided that Medicare rules for coverage of the medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 99053 provided on June 25, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for skilled nursing facility (SNF) care provided from May 19, 2020, to May 29, 2020, and billed with a Patient-Driven Payment Model (PDPM) of JEGF1.
You asked the Plan to pay for SNF care. You say that this was billed correctly. The Plan denied your request. The Plan says the records do not support that the enrollee had a swallowing disorder and septicemia.
The Plan must follow Medicare rules. Medicare rules say that SNF services are paid under the SNF PDPM prospective payment system (PPS). Under this system, each digit of the Health Insurance Prospective Payment System (HIPPS) code corresponds to a different case-mix group aspect of the SNF care provided. 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 SNF care. Our reviewer says that the billed PDPM is not supported. Our physician reviewer found the documentation does not indicate that the enrollee required significant skilled therapy for dysphagia or septicemia. 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 pay for skilled nursing facility (SNF) care provided from May 19, 2020, to May 29, 2020, and billed with a Patient-Driven Payment Model (PDPM) of JEGF1.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve risk assessment and documentation, with a finding of high risk (D0603) provided by a participating provider.
You asked the Plan to pre-approve risk assessment and documentation. You say that the patient is hurting and cannot eat. The Plan denied your request. The Plan says this is not a covered service.
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, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve risk assessment and documentation, with a finding of high risk (D0603) provided by a participating provider.
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 records do not show that the care the enrollee needs can only be given in a hospital setting, or that the enrollee will require an LTACH for 25 or more days.
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. 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: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Zip Fusion device (CPT code(s): 22612, 22840, 22842)
for the enrollee.
You asked the Plan to pre-approve the surgery. You say that the surgery is necessary. The Plan denied your
request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to
insufficient evidence of efficacy.
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 the surgery. Our reviewer says that the
requested items/services are not considered medically reasonable and necessary in this case. Our physician
reviewer found the Zip Fusion device remains experimental. More research is needed to show safety and
efficacy of the device.
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 surgery have not been met. Therefore, we decided that the Plan does not
have to pre-approve Zip Fusion device (CPT code(s): 22612, 22840, 22842) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the plastic surgery consultation to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve the plastic surgery consultation. You say that you no longer want to see the in-network provider because you do not agree with the treatment plan. The Plan denied your request. The Plan says the provider is out-of-network.
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. The records provided for review do not show that the service at issue is urgent or emergent. Therefore, we decided that the Plan does not have to pre-approve the plastic surgery consultation to be provided by an out-of-network (OON) provider
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from June 15, 2020, to June 20, 2020, and billed with DRG (diagnosis related group) 637.
You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your request. The Plan says the records do not support the secondary diagnosis of G92.
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 637, diabetes with major complications or comorbidities, and diagnosis G92, toxic encephalopathy. 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 although metabolic encephalopathywas noted, there was no clear documentation of the member's baseline supported by neurological examination findings documented by licensed provider corroboration. There is no evidence of a diagnostic work up done for encephalopathy. 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 June 15, 2020, to June 20, 2020, and billed with DRG (diagnosis related group) 637.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the inpatient services provided June 4, 2020, to June 8, 2020,
billed with DRG 391.
You asked the Plan to pay for the inpatient services billed with DRG 391. You say that you would like the plan
to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by
the documentation.
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 secondary diagnosis codes of J96.22, defined as
acute and chronic respiratory failure with hypercapnia and J96.21, defined as acute and chronic respiratory
failure with hypoxia. 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 the inpatient services
billed with DRG 391. Our reviewer says that the documentation does not support the DRG billed. Our
physician reviewer found the enrollee was admitted with duodenitis without bleeding. The enrollee complained
of shortness of breath but has a history of COPD. There was no documentation of acute or chronic respiratory
failure. The enrollee was maintained on 2-3 Liters of oxygen and no arterial blood gases were obtained. There
was no documentation of any treatment for acute respiratory failure. The review has determined that the
documentation does not support the billing of the secondary diagnosis codes billed.
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 the inpatient services provided June 4, 2020, to June 8, 2020, billed with DRG 391.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702).
You asked the Plan to pre-approve the orthotic device. You say that given his history and his inability to independently carry out his activities of daily living, the enrollee has been referred by his family practice nurse practitioner for myoelectric orthotic restoration. The Plan denied your request. The Plan says this item is considered experimental and investigational. There is insufficient evidence of its effectiveness in those with stroke and hemiparesis.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered. The rules also say that experimental and investigational devices are not covered. We looked at the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the orthotic device have not been met. Therefore, we decided that the Plan does not have to pre-approve the MyoPro Motion G orthotic device (L8702).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a root canal (D3310) for tooth # 11, a partial lower denture with flexible base (D5226), and a crown (D2750) for tooth # 18.
You asked the Plan to pre-approve the dental services. You say that the root canal should be covered. You say that the tooth is decayed. You also say that you need a root canal before you can get the crown that was approved. The Plan denied your request. The Plan says root canal is not a covered dental service. The Plan says that partial lower denture with a flexible base is not listed as a covered dental service. The Plan says that crowns are covered once per tooth every 60 months. The Plan also says that the frequency limit has been reached.
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, the requested root canal and partial lower denture with a flexible base are not among those covered under this benefit.
Additionally, the frequency limit for crowns has been reached. The record shows that the Plan paid for a crown for tooth # 18 that you received on May 19, 2020. Therefore, we decided that the Plan does not have to pre-approve a root canal (D3310) for tooth # 11, a partial lower denture with flexible base (D5226), and a crown (D2750) for tooth # 18.
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 the requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.
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 you do not require an intensive, complex, multidisciplinary approach to daily therapy. While you may benefit from physical therapy and occupational therapy, your rehab needs can be safely met in an alternate and low intensity setting such as in home with therapies. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the suture of small intestine (44603) provided on January 25, 2021.
You asked the Plan to pay for the suture of small intestine. You say that you would like this claim reprocessed based on the documentation provided. The Plan denied your request. The Plan says an appropriate modifier was not billed 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 code 44603 is a column II code to column I code 44120. 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 suture of small intestine (44603) provided on January 25, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve inpatient mental health care.
You asked the Plan to pre-approve inpatient mental health care. You say that the stay is medically necessary.
The Plan denied your request. The Plan says the stay is not medically necessary.
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 inpatient mental health care. Our
physician reviewer found based upon review the records provided for the admission of this enrollee does not
meet criteria for acute inpatient mental health treatment as this enrollee was not shown to be a danger to
themself or others, no auditory or visual hallucinations. The enrollee is noted to be cooperative and compliant
with treatment while not showing any aggressive behaviors.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the
Plan does not have to pre-approve inpatient mental health care.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation with fundus photography and scanning computerized ophthalmic diagnostic imaging to be provided by the requested out-of-network provider.
You asked the Plan to pre-approve an office consultation with fundus photography and scanning computerized ophthalmic diagnostic imaging to be provided by the requested out-of-network provider. You say that you have wet macular degeneration in both eyes, and you need eye injections every 1-2 months and that is why you need to see a retina specialist which is much closer to your home and offers a laser option. The Plan denied your request. The Plan says the service must be emergent or not available within the Plan's medical group network in order to use a non-contracted provider. The Plan says the in-network retina specialists perform laser treatment for exudative age-related macular degeneration and are 4 minutes from your home.
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 and accessible who can provide the services at issue in this appeal. We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that the Plan does not have to pre-approve an office consultation with fundus photography and scanning computerized ophthalmic diagnostic imaging to be provided by the requested out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a right total hip arthroplasty.
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 x-rays and computerized tomography of the right hip show only mild bone changes.
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. You are being treated for unilateral primary osteoarthritis of the right hip. You presented with continued right hip pain. You state that the pain and fatigue have been worsening and making it difficult for you to ambulate. Exam reveals pain with palpation. There is limited range of motion and strength due to pain. There is pain on internal and external range of motion. Weakness is noted in the quadriceps. However, detailed documentation is not evident regarding severe arthritic process in the right hip. The imaging studies, x-rays and computerized tomography (CT) show only mild pathology. In addition, there are no significant, red-flag, findings on exam to support the need for surgery in this mild disease process.
Our physician reviewer found that your condition does not meet Medicare criteria for 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 a right total hip arthroplasty.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.
You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan
denied your request. The Plan says that your rehab and medical needs can be met with part-time skilled
services in a lower level of care.
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 services. Our reviewer says that
daily skilled services are not necessary. Our physician reviewer found that your condition does not meet
Medicare criteria for SNF 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 SNF services have not been met. Therefore, we decided that the Plan does not
have to pre-approve skilled nursing facility (SNF) services.