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

 We decided that the Plan does not have to pre-approve a seat lift mechanism.  You asked the Plan to pre-approve a seat lift mechanism. You say that you have to sleep in your wheelchair sometimes because you can't stand and cannot move yourself in bed. The Plan denied your request. The Plan says you do not meet Medicare criteria for coverage of this device.  The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section 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 pre-approve a seat lift mechanism. Our reviewer says that a seat lift mechanism is not medically necessary at this time. Our physician reviewer found the documentation does not reveal objective imaging evidence of documentation of (a) severe arthritis of the hip or knees and/or (b) a neuromuscular disease.  The patient is documented to have osteoarthritis of the hands, shoulders, hips, knees but the severity of the arthritis in the joints is not clear without objective imaging study results. The medical progress notes do include a seat lift in the course of treatment. The seat lift is not likely to effect improvement in your condition. The records do not show that you are totally incapable of standing from a chair in the home.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a seat lift mechanism have not been met. Therefore, we decided that the Plan does not have to pre-approve a seat lift mechanism.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the unlisted nervous system procedure (64999)  You asked the Plan to pay for the unlisted procedure. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service billed.  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 64999 is unlisted procedure, nervous system.  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 unlisted procedure. Our reviewer says that CPT code 69999 does not meet criteria for billing or reimbursement consideration.  Our reviewer found the procedure report documents an anesthetic agent injection, there is a more appropriate code to report for this service. Per CPT guidelines services should always be coded to the highest specificity.  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 unlisted procedure have not been met. Therefore, we decided that the Plan does not have to pay for the unlisted nervous system procedure (64999)
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for an unlisted multianalyte assay with algorithmic analysis (81599) provided on November 13, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for an unlisted multianalyte assay with algorithmic analysis. You say that are requesting an appeal and you submitted supporting documentation. You also say that some of the attached documents are medical records for the enrollee pertaining to your date of service and the requisition form confirms the test was ordered by the patient's treating physician. The Plan denied your request. The Plan says the non-urgent services are not authorized because the provider is a non-network provider with the Plan and another non-network provider referred the member for services.  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 an unlisted multianalyte assay with algorithmic analysis (81599) provided on November 13, 2020, by an out-of-network (OON) provider.
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 the admission. You say that this is medically necessary. The Plan denied your request. The Plan says there are no daily skilled nursing needs.  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 the admission. Our reviewer says that the requested admission is not medically reasonable or necessary. Our physician reviewer found you have stabilized medically stable and is ready for discharge from the hospital. You do not require skilled nursing and/or skilled therapy services on a daily basis. You are medically stable and can receive further rehabilitation services at a lower level of care. Although further rehabilitation services would be appropriate to improve function, as a practical matter, the intermittent skilled services can be provided at a lower level of care than a skilled nursing facility. You do not have any parenteral medication, complex wound care, or nutrition via a feeding tube. You are medically stable without any acute exacerbations of chronic medical problems. Your physical function is at or near the new baseline, and the services can be received at a lower 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 the admission 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: 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 the clinical documentation provided supports the need for LTACH care. The Plan denied your request. The Plan says LTACH care 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 there is no documentation provided indicating medical necessity for LTACH services. 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. 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: 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 you would like reconsideration because the LTACH services are medically necessary. The Plan denied your request. The Plan says the member does not meet Medicare criteria for coverage of the LTACH services.  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 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. Our physician reviewer found the enrollee is receiving appropriate care at the present acute care hospital. 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.  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 pay for the skilled nursing facility (SNF) care provided on July 18, 2021.  You asked the Plan to pay for the SNF care. You say that the services are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee did not receive daily skilled services during the dates of service in this case.  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 pay for the SNF care. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the SNF care have not been met. Specifically, the file does not indicate that the enrollee received skilled services on the date of service in this case. Therefore, we decided that the Plan does not have to pay for the skilled nursing facility (SNF) care provided on July 18, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve continuation of admission to a skilled nursing facility (SNF) for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says the enrollee meets the discharge criteria for skilled nursing facility services.  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 the services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee 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 the services have not been met. Therefore, we decided that the Plan does not have to pre-approve continuation of admission to a skilled nursing facility (SNF) for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve an Intracept procedure.  You asked the Plan to pre-approve an Intracept procedure. You say that the requested procedure fills a treatment gap for those patients that do not receive adequate relief from traditional conservative methods and don't have instability to indicate fusion. You say that the enrollee has tried and failed conservative treatment without relief. The Plan denied your request. The Plan says the requested surgery is considered experimental and investigational.  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 an Intracept procedure. Our reviewer says that an Intracept procedure is not considered medically reasonable and necessary in this case. Our physician reviewer found the Intracept procedure is experimental. More research is needed to show safety and efficacy.    We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of an Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve an Intracept procedure.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the special stain provided on July 6, 2021.  You asked the Plan to pay for the services provided. You say that there was clinical concern of a possible fungal infection. The Plan denied your request. The Plan says the documentation submitted does not meet the requirements.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   In this case, the CPT Code Manual definition of code 88312 is special stain including interpretation and report; Group I for microorganisms (e.g., acid fast, methenamine silver). We find that CPT code 88312 is not supported in the medical record. The records do not show that the special stain was ordered due to primary test results being inconclusive. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the special stain provided on July 6, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70544) provided on September 13, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled 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 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 the services (70544) provided on September 13, 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 the information provided supports the need for IRF care. The Plan denied your request. The Plan says the guidelines for coverage have not been met. The Plan says that the enrollee can safely receive the care needed in other settings.  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 enrollee with debility from acute illness, is medically stable. With her comorbid conditions being stable, she does not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. There are no acute or complex rehabilitation nursing needs noted in the record. At the current functional level, the enrollee does not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. An IRF admission is not medically necessary based on lack of medical complexity, and rehabilitation nursing needs and high functional mobility. While the enrollee may benefit from physical therapy, occupational therapy and speech therapy, the enrollee's rehabilitation needs can be safely met in an alternate and lower intensity setting such as in an SNF.  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: Favorable

 We decided that the Plan has to pay for the office visit (99213) provided on September 21, 2021.  You asked the Plan to pay for the office visit. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says that CPT code 99213 falls within the global period of another service rendered 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 99213-25 is  office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using time for code selection, 20-29 minutes of total time is spent on the date of the encounter.   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 office visit. Our reviewer says that CPT code 99213 meets criteria for billing and reimbursement consideration. Our reviewer found services are separately identifiable when a re-evaluation or new acute problem arises. In this case, evaluation and management documentation describes a re-evaluation of an established patient's progress under a current treatment plan.  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 office visit have been met. Therefore, we decided that the Plan has to pay for the office visit (99213) provided on September 21, 2021.   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: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the pelvic ultrasound rendered on September 18, 2021.  You asked the Plan to pay for these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not separately payable.  The rules say that, for edits with a modifier indicator of 1, the Column 2 code is payable only if a clinically appropriate NCCI modifier is used to report the reason it should be paid as well.     The provider submitted a claim for procedure codes 76857 (limited pelvic ultrasound) and 76775 (retroperitoneal ultrasound). Code 76857 is a column II code with a modifier indicator of 1 when billed with column I code 76775. Code 76857 was not billed with an appropriate modifier to allow for separate payment. Therefore, we decided that the Plan does not have to pay for the pelvic ultrasound rendered on  September 18, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis L3960 ankle/foot orthosis (L1971) and heel stabilizer (L3170) provided March 31, 2021.  You asked the Plan to pay for the orthoses. You say that please see the attached medical records as requested. The Plan denied your request. The Plan says the claim is denied misrepresentation of services, documents do not sufficiently support the billed supply code and records do not indicate the provider discussed the need for the billed supply code.  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 pay for the orthoses. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the review has determined that the documentation submitted did not sufficiently support the billed supply code; nor did documentation indicate the provider discussed the need for the billed supply code. The medical records provided did not meet the requirements listed in the LCD for Medicare coverage.  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 orthoses have not been met. Therefore, we decided that the Plan does not have to pay for the shoulder elbow wrist hand orthosis L3960 ankle/foot orthosis (L1971) and heel stabilizer (L3170) provided March 31, 2021.