Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the inpatient psychiatric services from September 26, 2021, forward.

You asked the Plan to pre-approve continued inpatient psychiatric services. You say that you believe the continued admission should be covered. The Plan denied your request. The Plan says the medical record indicates that your condition had improved, and you were no longer a threat to yourself or others.

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 psychiatric services. Our reviewer says that the continued inpatient psychiatric admission from September 26, 2021, forward is not medically necessary. Our physician reviewer found that you did not require inpatient mental health treatment beyond the dates in question as you were not a danger to yourself or others and did not have any auditory or visual hallucinations or behavioral issues. It did not appear that active treatment was taking place beyond the date in question. It did not appear that the services for the dates in question were reasonably expected or medically necessary to improve your condition or for the purpose of diagnosis. Based upon review of the records provided, you do not meet the criteria for treatment in an acute inpatient mental health treatment from September 26, 2021, forward. You could have been treated in a lesser restrictive setting as you were not showing any suicidal or homicidal ideation, auditory or visual hallucinations and were not showing any aggressive behaviors, being cooperative and compliant. 

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 psychiatric services have not been met. Therefore, we decided that the Plan does not have to pre-approve the inpatient psychiatric services from September 26, 2021, forward.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on February 24, 2021.

You asked the Plan to pay for the physical therapy services. You say that plans are required to pay non-contracted providers at the preferred provider rate if services are not available from preferred providers in the service area. You say that the in-network benefits should be honored, and the claim processed for payment. The Plan denied your request. The Plan says the records do not support the service billed.

The Plan must follow Medicare rules. Medicare rules say that the services of a PTA shall not be billed as services incident to a physician/non-physician practitioner's (NPP) service, because they do not meet the qualifications of a therapist. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the physical therapy services have not been met. Specifically, the billing provider is a nurse practitioner, and not a licensed therapist. As such, PTA services cannot be paid incident to this provider's professional services. Therefore, we decided that the Plan does not have to pay for physical therapy services provided by a physical therapy assistant on February 24, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
You asked the Plan to pre-approve a power seat elevation feature. You say that this request is medically necessary. The Plan denied your request. The Plan says this is not a covered item.
The Plan must follow Medicare rules. Medicare rules say that a power seat elevation feature is non-covered because it is not primarily medical in nature. We looked at the file and Medicare rules. In this case, this item is statutorily non-covered by Medicare. Based on this information, we decided that Medicare rules for coverage of a power seat elevation feature have not been met. Therefore, we decided that the Plan does not have to pre-approve a power seat elevation feature (E2300).
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a second opinion office consultation to be rendered by the out-of-network (OON) provider.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.

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 service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve a second opinion office consultation to be rendered by the out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality (76376) provided April 10, 2021.

You asked the Plan to pay for the diagnostic service. You say that please review the attached radiology reports and process the claim for payment under the facility authorization/precert/referral as you bill for the professional component only. The Plan denied your request. The Plan says radiologic techniques using 3D rendering will be considered integral to the radiology services and not a separate 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 the diagnostic service has a bundled relationship with code 74181 and cannot be paid as billed. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for 3D rendering with interpretation and reporting of computed tomography, magnetic resonance imaging, ultrasound, or other tomographic modality (76376) provided April 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit to be rendered by an out-of-network (OON) provider.
You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.
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. You are not a network provider with the Plan. The Plan has network providers available who can provide the service at issue in this appeal. We found no exception that would require the Plan to pre-approve this service. Therefore, we decided that the Plan does not have to pre-approve an office visit to be rendered by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex surgery.
You asked the Plan to pre-approve the Vertiflex surgery. You say that this device is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this procedure is considered experimental/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 the Vertiflex surgery. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device 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 the Vertiflex surgery have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex surgery.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for application of skin substitute graft provided on May 5, 2021.

You asked the Plan to pay for application of skin substitute graft (15271). You say that the Plan should pay this claim. The Plan denied your request. The Plan says documentation does not indicate the application of a skin substitute graft was applied.

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 15271 is application of skin substitute graft to trunk, arms, legs, total wound surface area up to 100 sq cm; first 25 sq cm or less wound surface area. 

We find that CPT code 15271 is not supported in the medical record. Specifically, there is no documentation of this procedure. Based on this information, we decided that Medicare rules for coverage of application of skin substitute graft (15271) have not been met. Therefore, we decided that the Plan does not have to pay for application of skin substitute graft provided on May 5, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided December 15, 2021.
You asked the Plan to pay for the ambulance response. You say that the enrollee should not be charged for an ambulance service because the services were not used. The Plan denied your request. The Plan says there is no coverage for ambulance services when there is no transport.
The Plan must follow Medicare rules. The rules say that Medicare does not pay for ambulance services when there is no transport.
The ambulance company did not provide transport services on December 15, 2020. The ambulance benefit is a transportation benefit. When there is no transport, neither Medicare nor the Plan pays for the services provided. There is no documentation in the case file to indicate that the wavier criteria are met. Therefore, we decided that the Plan does not have to pay for the ambulance response and treatment, no transport (A0998) provided December 15, 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 enrollee needs acute rehab to regain his strength.
The Plan denied your request. The Plan says the enrollee does not need an intensive team for 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 physician reviewer found
that the enrollee was admitted to the acute care hospital for right leg pain ad weakness after a recent stroke. His
medical problems are stable. 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.

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: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Group 3 power wheelchair with single power option,
power tilt, power elevating leg rests and other attachments.

You asked the Plan to pre-approve these items. You say that these items are medically necessary. The Plan
denied your request. The Plan says that a Group 3 power wheelchair with single power option exceeds your
need and cannot be covered.

The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair with single power
option, power tilt and power elevating leg rests can be covered if LCD 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 pre-approve these items. Our reviewer says that
these items are not medically reasonable and necessary. Documentation indicates on the physician exam that
you have mild dementia and evidence of nystagmus on examination; therefore, it is not clear if your vision and
cognition are acceptable and safe for maneuvering a power mobility device. Furthermore, the power tilt is not
medically necessary as you are not noted to be at a high risk for pressure ulcer and use intermittent
catheterization. The documentation notes that you are hypertonic and on tizanidine however the physician
documentation does not indicate evidence of spasticity on a physical exam that requires the power seating
system for management. Our physician reviewer found that your condition does not meet Medicare criteria for
these items.

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 items have not been met. Therefore, we decided that the Plan does not
have to pre-approve a Group 3 power wheelchair with single power option, power tilt, power elevating leg rests
and other attachments.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the surgical services rendered on February 9, 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 procedure code 62145 is not supported.

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.
Providers must report services with the appropriate CPT code.

In this case, the CPT Code Manual definition of code 62145 is cranioplasty for skull defect with reparative
brain surgery.

We find that CPT code 62145 is not supported in the medical record. Specifically, there is no documentation of
cranioplasty for skull defect with reparative brain surgery. Based on this information, we decided that Medicare
rules for coverage of these services have not been met.

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 20660 (application of cranial tongs or stereotactic frame),
62100 (repair of brain fluid leakage), and 61315 (craniectomy or craniotomy for evaluation of hematoma).
Codes 20660 and 62100 are column II codes with a modifier indicator of 1 when billed with column I code
61315. Codes 20660 and 62100 were not billed with an appropriate modifier to allow for separate payment.

Therefore, we decided that the Plan does not have to pay for the surgical services rendered on February 9,
2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion (eg, corn or callus) (11055) provided March 2, 2021.

You asked the Plan to pay for the podiatry services. You say that you already paid $40 and that should be sufficient. You do not think you should have to pay for it. The Plan denied your request. The Plan says the records do not support that the enrollee meets the Medicare criteria for coverage of the routine foot care services.

The Plan must follow Medicare rules. The rules say that routine foot care is not covered. The only exception is for those who have a condition that results in severe loss of circulation or areas of poor sensation in the legs or feet or have fungal nails.

Records do not show that any of these conditions are present. The claim was not billed with a diagnosis that would support medical necessity per Local Coverage Article A57759: Billing and Coding: Routine Foot Care and Debridement of Nails. The services you are asking the Plan to pay for are routine foot care services. Based on this information, we decided that Medicare rules for coverage of the podiatry services have not been met. Therefore, we decided that the Plan does not have to pay for the paring or cutting of benign hyperkeratotic lesion (eg, corn or callus) (11055) provided March 2, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for shoulder arthroscopy (29806) provided on April 15, 2021.

You asked the Plan to pay for shoulder arthroscopy 29806. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the records do not support that this was a separate unrelated procedure and it is not eligible for payment.

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 29806 is arthroscopy, shoulder, surgical; capsulorrhaphy. 

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 shoulder arthroscopy 29806. Our reviewer says that code 29806 does not meet the Medicare criteria for payment. Our reviewer found the operative report does not support code 29806 as a separate unrelated procedure from the primary code. When a procedure or service that is designated as a "separate procedure" is carried out independently or considered to be unrelated or distinct from other procedures reported the code in addition to other procedures/services by appending modifier 59 to the specific "separate procedure" code. If the procedure is in the same anatomic area as a more comprehensive procedure, only more comprehensive procedure is reported. In this case, documentation does not support a separate procedure from the primary, and therefore, would not be covered.

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of shoulder arthroscopy 29806 have not been met. Therefore, we decided that the Plan does not have to pay for shoulder arthroscopy (29806) provided on April 15, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (1 unit) (CPT code 62323).

You asked the Plan to pre-approve the injection. You say that the injection is necessary. The Plan denied your request. The Plan says no more than two injections to the area where a nerve root exits (transforaminal) can be done during a single setting. The Plan states one caudal or lumbar interlaminar injection per session and not in conjunction with a transforaminal injection. The Plan states the request exceeds the amount allowable in a single setting.

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 injection. Our physician reviewer found there is no medical need for two (2) same level lumbar epidural steroid injection (ESI) injections. The pathology only necessitates one injection. Second not needed. 

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 injection have not been met. Therefore, we decided that the Plan does not have to pre-approve injection(s), of diagnostic or therapeutic substance(s) (eg, anesthetic, antispasmodic, opioid, steroid, other solution), not including neurolytic substances, including needle or catheter placement, interlaminar epidural or subarachnoid, lumbar or sacral (caudal); with imaging guidance (1 unit) (CPT code 62323).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided on April 26, 2021, to May 3, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for inpatient hospital services. You say that you cancelled your coverage with this Plan. The Plan did not cancel your insurance after you signed up with a different Plan and all the claims were sent to them and denied. You also say that the Plan was paid by Medicare, but they are not paying claims. The Plan denied your request. The Plan says you 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. This hospital is not a network provider with the Plan.
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 hospital in this case is not a network provider with the Plan. The Plan had network hospitals available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. The records provided for review do not show that the services at issue were urgent or emergent. 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 inpatient hospital services provided on April 26, 2021, to May 3, 2021, by an out-of-network (OON) provider.