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

 We decided that the Plan does not have to pay for the acute inpatient hospital care for the knee surgery (CPT code 27447). 

 You asked the Plan to pay for acute inpatient hospital care. You say that the stay is necessary. The Plan denied your request. The Plan says Medicare considers this an outpatient procedure. The Plan states there is no documentation of why you need this to be done as an inpatient. 

 The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.    

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 acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found recent notes did not reveal an unstable clinical situation or medical history which would expect hospital services related to this typically ambulatory surgery to cross two (2) midnights.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care for the knee surgery (CPT code 27447).
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for an ultrasound (procedure code 76700) provided to the enrollee on August 20, 2021.

You asked the Plan to pay for the ultrasound. You say that this should be paid for. The Plan denied your request. The Plan says the appropriate modifier was not 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, we have confirmed that code 76700 is a column II code to column I code 93976. 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 an ultrasound (procedure code 76700) provided to the enrollee on August 20, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Intracept procedure.  

You asked the Plan to pre-approve the Intracept procedure. You say that the requested services are medically necessary for the enrollee's condition. The Plan denied your request. The Plan says the requested 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 Intracept procedure. Our reviewer says that the requested items/services are 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 before coverage for this can be approved.  

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 Intracept procedure have not been met. Therefore, we decided that the Plan does not have to pre-approve the Intracept procedure.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve use of Botox. 

 You asked the Plan to pre-approve Botox. You say that you do not use either Dysport or Xeomin and are not trained in the administration of them. The Plan denied your request. The Plan says the denial of authorization for this drug is correct, because the Plan requires a trial of Dysport or Xeomin before it will approve Botox. 

 Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.  

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 Botox. Our reviewer says that the enrollee does not meet the Medicare criteria for a step therapy exception for Botox. Our physician reviewer found the enrollee has not tried and failed the Plan's preferred drugs of Dysport or Xeomin. The record does not show that these drugs would likely be less effective and/or have adverse effects for the enrollee.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of Botox have not been met. Therefore, we decided that the Plan does not have to pre-approve use of Botox.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pre-approve inpatient psychiatric services.  You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that the clinical information provided supports the need for inpatient psychiatric care. The Plan denied your request. The Plan says that the enrollee has no medical problems that require hospital care.  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 hospital services. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee was involuntarily admitted to the acute inpatient psychiatric hospitalization on December 16, 2021, with Major Neurocognitive Disorder, Unspecified with Behavioral Disturbance and Impulse Control Disorder. The enrollee presented with aggressive behavior, delusional thinking and verbal aggression. The enrollee was showing behaviors which were threatening and was showing acute safety issues. It did appear medically necessary and reasonable to have psychiatric care provided at the acute inpatient level of care rather than a lower level of care. This enrollee did appear to require inpatient mental health treatment as she was showing aggressive behaviors toward her husband. It did appear that active treatment was taking place. It did appear that the services were reasonably expected to improve the enrollee's condition or were for the purpose of diagnosis. It appears that the records were supervised and evaluated by a physician. Based upon review the records provided, this enrollee does meet criteria for acute inpatient mental health treatment as she was showing acute threat to safety of aggression toward her husband.  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 hospital services have been met. Therefore, we decided that the Plan has to pre-approve inpatient psychiatric services.   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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the home infusion therapy (S9338) provided from March 30, 2021, through March 31, 2021.  

You asked the Plan to pay for the home infusion therapy. You say that you would like this claim reprocessed based on the medical documentation. The Plan denied your request. The Plan says this code as billed is not valid for Medicare purposes.  

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 S9338 is home infusion therapy, immunotherapy, administrative services, professional pharmacy services, care coordination, and all necessary supplies and equipment (drugs and nursing visits coded separately), per diem.  

We find that CPT code S9338 is not eligible for payment according to Medicare rules. Specifically, this code has a status indicator of "I" under the Physician Fee Schedule. Medicare uses another code for reporting of, and payment for, these services. Based on this information, we decided that Medicare rules for coverage of the home infusion therapy have not been met. Therefore, we decided that the Plan does not have to pay for the home infusion therapy (S9338) provided from March 30, 2021, through March 31, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected (0202U) provided on June 26, 2021 to June 27, 2021.  

You asked the Plan to pay for code 0202U. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered.  

The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.  

We looked at the file and Medicare rules. Medicare says that code 0202U is not covered. Therefore, we decided that the Plan does not have to pay for the Infectious disease (bacterial or viral respiratory tract infection), pathogen-specific nucleic acid (DNA or RNA), 22 targets including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), qualitative RT-PCR, nasopharyngeal swab, each pathogen reported as detected or not detected (0202U) provided on June 26, 2021 to June 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the durable medical equipment provided on July 11, 2021 to September 11, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for the durable medical equipment provided by an OON provider. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services provided were neither emergent nor urgent and prior authorization was not obtained to provide out-of-network care.  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 the durable medical equipment provided on July 11, 2021 to September 11, 2021 by an out-of-network (OON) provider.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pay for home infusion services (99601, S9328, S9363, A4220) provided April 26, 2021.  

You asked the Plan to pay for the home infusion services. You say that the services were medically necessary. The Plan denied your request. The Plan says the billed codes are not eligible for Medicare 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.  

We find that CPT codes 99601, S9328, S9363 and A4220 are not supported in the medical record. Specifically, CPT codes 99601, S9328, & S9363 have a status of "I" per the National Physician Fee Schedule and are invalid for Medicare purposes. CPT code A4220 has a status of "B" and payment is always bundled with another service. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pay for home infusion services (99601, S9328, S9363, A4220) provided April 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on May 4, 2021.  You asked the Plan to pay for the laboratory services. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered as billed.  The Plan must follow Medicare rules. The rules say that laboratories shall not report multiple individual CPT codes describing the component test results.  We find that the various denied CPT codes are not supported in the medical record. Specifically, the testing at issue in this case should be reported with CPT code 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 4, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided on July 1, 2021.  You asked the Plan to pay for a full mouth debridement. You say that you had a dental cleaning, and you disagree with the denial. The Plan denied your request. The Plan says there is no coverage for the service requested. The Plan also says that you did not contact the Plan prior to the date of service to verify benefits.  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. Specifically, a full mouth debridement is not listed as a covered benefit with your Plan. Therefore, we decided that the Plan does not have to pay for a full mouth debridement to enable a comprehensive oral evaluation and diagnosis on a subsequent visit (D4355) provided on July 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit (99203), arthrocentesis (20600), and immunization (J1030) provided on August 2, 2021, by an OON provider.  

You asked the Plan to pay for the office visit, arthrocentesis, and immunization. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says criteria for use of a non-par provider per the evidence of coverage have not been met due to services not being emergent, not being dialysis related, and due to par provider's being available in member's area  

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 the office visit (99203), arthrocentesis (20600), and immunization (J1030) provided on August 2, 2021, by an OON provider.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on March 1, 2020, through March 7, 2020 and billed with Patient Driven Payment Model (PDPM) code GAXE1 x 7 days.  You asked the Plan to pay for the SNF services billed with PDPM code GAXE1 x 7 days. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation does not support coding of Ulcerative Colitis, Crohn's Disease, or Inflammatory Bowel Disease.  The Plan follows Medicare rules. Medicare rules say that all SNF Part A inpatient services are paid under a prospective payment system (PPS). This involves payment based on a Health Insurance Prospective Payment System (HIPPS) rate code.  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 services billed with PDPM code GAXE1 x 7 days. Our reviewer says that the enrollee is noted to have gastroesophageal reflux diseaseand diverticulitis.  There is no evidence that the enrollee has ulcerative colitis, Crohn's or irritable bowel syndrome. Our physician reviewer found billing in relation to those diagnoses is not supported.  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 services billed with PDPM code GAXE1 x 7 days have not been met. Therefore, we decided that the Plan does not have to pay for the Skilled Nursing Facility (SNF) services provided on March 1, 2020, through March 7, 2020 and billed with Patient Driven Payment Model (PDPM) code GAXE1 x 7 days.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for procedure code 35701 billed for date of service June 29, 2020.  You asked the Plan to pay for procedure code 35701. You say that you have provided medical records to substantiate payment. The Plan denied your request. The Plan says procedure code 35701 is bundled into code 15758 billed on the same date of 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 procedure code 35701 is a column II code to column I code 15758. 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 procedure code 35701 billed for date of service June 29, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve office visit services with an out of network (OON) oncologist.  

You asked the Plan to pre-approve the OON office visit services. You say that you were advised you should be seen at the requested OON facility because they can offer the best treatment for your condition. The Plan denied your request. The Plan says there is appropriate and timely services available with an in network surgical oncologist.  

Medicare rules generally allow plans to restrict enrollees to using plan providers as long as there are plan providers available to meet enrollees' needs. Your contract with the Plan says that, with few exceptions, you must use contract providers for care.   

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 OON office visit services. Our reviewer says that the criteria for coverage of OON care have not been met. Our physician reviewer found the Plan's denial is medically justified on the basis that it is offering adequate care to meet the enrollee's medical needs through referral to an in-network surgical oncologist. The enrollee needs a bronchoscopy, which is available within the network. If the bronchoscopy is negative for metastatic disease then breast surgery would be needed, which is also available within the network. There is nothing unique about the enrollee's condition that would make it medically necessary for her to see the requested OON provider. The Plan has shown that they have in-network providers who meet the Standards of Care required for treatment of the enrollee's condition.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of OON care have not been met. Therefore, we decided that the Plan does not have to pre-approve office visit services with an out of network (OON) oncologist.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for an office visit and x-ray examinations provided on August 25, 2021.  You asked the Plan to pay for office visit and x-rays. You say that these services are necessary for your health. The Plan denied your request. The Plan says the denial of payment for these services is correct, because these services are not covered by Medicare or the Plan when performed by a chiropractor.  The Plan must follow Medicare rules. The rules say that the only chiropractic service Medicare covers is manual manipulation of the spine to correct a subluxation.   The records show that the services at issue are not manual manipulation of the spine. Therefore, we decided that the Plan does not have to pay for an office visit and x-ray examinations provided on August 25, 2021.
Appeal type: Lab
Decision: Favorable

 We decided that the Plan has to pay for an additional unit of x-ray imaging (procedure code 71045) provided to the enrollee on December 20, 202.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says that there is no additional documentation supporting payment for an additional study.  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 71045 is "Radiologic examination, chest; single view."  We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were supported by the medical records. Our reviewer found two separate chest x-rays at different times on 12/20/20 are in the records. Accession 8478852 and Accession 8480712 are documented in the records with both exams done on 1/20/20. Thus, the reimbursement for the second chest x-ray should be made.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have been met. Therefore, we decided that the Plan has to pay for an additional unit of x-ray imaging (procedure code 71045) provided to the enrollee on December 20, 202.   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.