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

We decided that the Plan does not have to pre-approve Viberzi tablet 100mg for the enrollee.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says the plan does not cover outpatient prescription drugs.

The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve Viberzi tablet 100mg for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care services totaling between 30-74 minutes (99291) provided on June 28, 2021.  You asked the Plan to pay for critical care services. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says the documentation does not support the services as billed.  The Plan must follow Medicare rules. Medicare rules say that critical care is a time-based service, and for each date and encounter entry, the physician's progress note(s) shall document the total time that critical care services were provided.   We looked at the file and Medicare rules. In this case, there is no documentation in the medical records of the time spent performing these services. Based on this information, we decided that Medicare rules for coverage of critical care services have not been met. Therefore, we decided that the Plan does not have to pay for critical care services totaling between 30-74 minutes (99291) provided on June 28, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for emergency care provided on September 7, 2021.  You asked the Plan to waive the copayment for emergency care. You say that the enrollee waited forever to be seen so left before being seen. The Plan denied your request. The Plan says the claims were processed correctly and the enrollee is being charged the correct 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). The enrollee's contract with the Plan clearly says that enrollees must pay a $90 copayment for emergency care.   The record shows that the enrollee received emergency care services on September 7, 2021. Therefore, they are responsible to pay the $90 copayment.     The enrollee has been asked to pay a $90 copayment for emergency care. Emergency care falls within the emergency care benefit category. This means that the enrollee has been asked to pay the correct amount based on the contract with the Plan. This cost sharing is a contractual obligation the enrollee agreed to pay upon enrolling in the Plan. Therefore, we decided that the Plan does not have to waive the copayment for emergency care provided on September 7, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services (99153) provided on July 11, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says this service is not payable.  The Plan must follow Medicare rules. Medicare rules say that the OPPS recognizes that CPT code 99153 is a practice expense (PE) only code and is not paid to the physician in the facility setting.         We find that payment for CPT code 99153 is not supported. Specifically, there is no separate payment for CPT code 99153 for services provided in the facility setting. Therefore, we decided that the Plan does not have to pay for the services (99153) provided on July 11, 2021.
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 you need inpatient rehabilitation. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The necessary services can safely be provided in a lower level of 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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve foreskin restoration procedure.  You asked the Plan to pre-approve foreskin restoration procedure. You say that this is medically necessary. The Plan denied your request. The Plan says this procedure is not medically necessary at this time.  The Plan must follow Medicare rules. Medicare rules say that cosmetic procedures and related services are not covered. Only services that are reasonable and necessary for the diagnosis or treatment of illness or injury are coverable.    We looked at the file and Medicare rules. In this case, the requested procedure is not reasonable and necessary for the diagnosis or treatment of an illness or injury. The requested procedure would be considered cosmetic in nature. Based on this information, we decided that Medicare rules for coverage of foreskin restoration procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve foreskin restoration procedure.
Appeal type: Home Health
Decision: Favorable

 We decided that the Plan has to pay for the home health services provided from July 11, 2020, through August 9, 2020, billed with payment code 2AC21.  You asked the Plan to pay for the home health services as billed. You say that you believe this payment was recouped in error because you were told that there were no issues found on the audit. The Plan denied your request. The Plan says that this cannot be paid as an early episode of care since the enrollee had a prior episode less than 60 days prior.  The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment.  The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. The Plan indicates that the code used is not supported as the first digit 2 indicates an early episode timing which is only used for the first 30-day episode of care, and all subsequent episodes are late, and should have a first digit of 4, unless 60 days have passed between the episodes. Although it is indicated that the patient had an episode of care from April 1, 2020, to May 30, 2020, no evidence of this was included in the file. As such, we cannot confirm the Plan's denial that the code used has the incorrect first digit. Therefore, we decided that the Plan has to pay for the home health services provided from July 11, 2020, through August 9, 2020, billed with payment code 2AC21.   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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance transport rendered on February 26, 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 claim is a duplicate.  The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied.  We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. The file supports that only one transport was rendered. 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 ambulance transport rendered on February 26, 2021.
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 inpatient rehab is necessary for you to regain your balance, endurance, problem solving, attention span, initiative and insight. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. You can safely receive the services you need in an alternate setting.  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 that the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. While the documentation does support a need for physical and/or occupational therapy, there is no documented need for an intensive, multi-disciplinary 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 inpatient rehabilitation facility (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.  You asked the Plan to pre-approve the LTACH services. You say that transfer to an LTACH is medically necessary for this enrollee. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee's medical needs are being met in the current acute setting. The LTACH would provide no additional services. With more time in the current setting, clinical stability can be ensured such that the appropriate lower level of care can be determined.  The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found there is no documentation provided indicating medical necessity for admission to a LTACH. 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/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. The requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the medical services coded as 20680 and 76000 provided on January 19, 2021.  You asked the Plan to pay for the medical services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says this claim has not been billed in accordance with 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 20680 is removal of implant; deep (eg, buried wire, pin, screw, metal band, nail, rod or plate). The CPT Code Manual definition of code 76000 is fluoroscopy (separate procedure), up to 1 hour physician or other qualified health care professional time.  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 medical services. Our reviewer says that the documentation does not support payment for the services as billed. Our reviewer found the medical records indicate that CPT 26520-F8 - Capsulectomy or capsulotomy, metacarpophalangeal joint, each joint was performed on January 19, 2021. CPT 20680 has a bundled relationship with CPT 26520; however, the use of an appropriate modifier to unbundle these services is allowed, providing the medical records support the use of the modifier. In this case, the medical records do not include sufficient documentation to validate that 20680 was performed as a distinct, separate procedure, therefore this service cannot be verified.   In addition, CPT 76000 has a Professional Technical Indicator of 1. Based on the place of service where this service was performed, the technical component of this service would be included in the facility reimbursement.  In order for the professional component to be considered for reimbursement, a 26 modifier would need to be appended to the code when billed.  In this case, 76000 was not billed with a 26 modifier, therefore no reimbursement is allowed.  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 medical services have not been met. Therefore, we decided that the Plan does not have to pay for the medical services coded as 20680 and 76000 provided on January 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for injection services (62320) provided on August 23, 2021.  You asked the Plan to pay for injection services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says despite multiple outreaches, clinical records that support the medical necessity of the rendered procedure have not been provided.  The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.     We looked at the file and Medicare rules. In this case, the Plan has sent several requests for medical records to the provider, but nothing has yet to be returned. Without sufficient medical records, we cannot evaluate if the services were medically reasonable and necessary. Based on this information, we decided that Medicare rules for coverage of injection services have not been met. Therefore, we decided that the Plan does not have to pay for injection services (62320) provided on August 23, 2021.
Appeal type: Home Health
Decision: Favorable

 We decided that the Plan has to pre-approve 6 additional home health skilled nursing visits.  You asked the Plan to pre-approve 6 additional home health visits. You say that the requested services are a medical necessity for you. The Plan denied your request. The Plan says that medical necessity rules for coverage of the requested services have not been met.  The Plan must follow Medicare rules. The rules say that home health care services may be covered if it is medically necessary for the enrollee to receive skilled nursing or therapy. A doctor must certify the need for home health care services.  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 6 additional home health visits. Our reviewer says that the requested services are medically necessary and reasonable in this case. Our physician reviewer found that the enrollee does have documented and intermittent skilled-nursing needs, in the form of twice-weekly dressing changes. While the cleansing of a wound and the application of ointment are easy enough for a patient or layperson to perform, the application of three-layer compression dressings is not so easily accomplished. The records clearly document that neither the enrollee nor the enrollee's caregiver are able, willing, or available to tend to this need.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 6 additional home health visits have been met. Therefore, we decided that the Plan has to pre-approve 6 additional home health skilled nursing visits.   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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan to be provided by an out-of-network provider.  You asked the Plan to pre-approve a PET-CT scan. You say that the service at issue is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage 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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  The requested provider in this case is not a network provider with the Plan. The Plan has network providers available who can provide the items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) with concurrently acquired computed tomography (CT) scan to be provided by an out-of-network provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for laparoscopy, surgical; repair initial inguinal hernia (CPT code 49650- AS) provided to the enrollee on April 9, 2021.  You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the service is not covered as billed.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. CPT code 49650-AS remains not supported. The documentation submitted indicates that assistant surgical services were performed by a Surgical Assistant. Although skilled, certified surgical technicians are not recognized for payment per the Center for Medicare/Medicaid Services (CMS) guidelines. Surgical assistants actively assist the physician performing a surgical procedure. Reimbursement for surgical assistant services is based on whether the assistant is a Physician or other health care professional. Medicare Part B pays for services provided by physicians and certain nonphysician practitioners, such as nurse practitioners, physician assistants and clinical nurse specialists. Other categories of nonphysician practitioners are not recognized as Medicare providers and thus are not able to bill the program independently for their services. Medicare cannot reimburse a surgical assistant's services if the assistant is an unlicensed practitioner and/or does not qualify to be a Medicare provider. Therefore, we decided that the Plan does not have to pay for laparoscopy, surgical; repair initial inguinal hernia (CPT code 49650- AS) provided to the enrollee on April 9, 2021.
Appeal type: ER
Decision: Unfavorable

 We decided that the Plan does not have to pay for the emergency department services (99284) provided on July 27, 2021.  You asked the Plan to pay for the emergency department services. You say that this claim has been billed appropriately. The Plan denied your request. The Plan says a modifier was not billed on the claim 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, we have confirmed that code 99284 is a column II code to column I code 99285. 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 emergency department services (99284) provided on July 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home health services provided to the enrollee from June 29, 2021, to July 27, 2021.  You asked the Plan to pay for home health services. You say that the RAP claim was received within the allowable time frame. The Plan denied your request. The Plan says the initial request for anticipated payments was not received timely.  The Plan must follow Medicare rules. The rules say that certain data elements on the RAP and the claim must be completed for home health care services to be covered.  We looked at the claim submitted, the file and the Medicare rules. The claim information provided does not indicate the notice of admission was submitted within 5 days after the admission date. Based on this information, we decided that Medicare rules for completing the claim for home health services have not been met. Therefore, we decided that the Plan does not have to pay for the home health services provided to the enrollee from June 29, 2021, to July 27, 2021.