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

 We decided that the Plan does not have to pay for radiology services (70450) provided August 14, 2021.  You asked the Plan to pay for the radiology services. You say that the services were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid as 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 70450 shares a bundled relationship with code 70496.  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 radiology services (70450) provided August 14, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve occupational therapy (OT) visits (97166).  You asked the Plan to pre-approve occupational therapy. You say that you need additional occupational therapy because your home exercise program does not provide the same kind of therapy and you feel your condition will grow worse without these services. The Plan denied your request. The Plan says the request for additional therapy is not reasonable and necessary as the records reviewed show that no functional progress has been made. The records do not show that maintenance therapy is needed to prevent further deterioration or to preserve existing function.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.  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 occupational therapy. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found that the additional therapy requested is not generally accepted as specific and effective therapy for your condition beyond what was approved by the health plan. You have had prior extensive therapy for this condition and the records do not demonstrate that the unique skills of a professional therapist are required to safely and effectively provide treatment, that the services can be safely and effectively performed only by a therapist, or by or under the supervision of a therapist. You have been instructed in a home exercise program. You are within normal function for ADL performance as noted on a document from October 16, 2021. The requested services are not part of a maintenance program, are the specialized skill, knowledge and judgment of a qualified therapist required to establish, design and/or deliver a program to maintain your current condition or to prevent or slow further deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of occupational therapy have not been met. Therefore, we decided that the Plan does not have to pre-approve occupational therapy (OT) visits (97166).
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on July 20, 2020.

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 covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered. 

The test at issue in this appeal, a cardiovascular risk assessment panel, was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on July 20, 2020.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on February 26, 2020.  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 was not filed timely.  The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010, must be filed no later than one calendar year after the date of service.    The record shows that a claim for these services was not filed until August 10, 2021. A valid Waiver of Liability (WOL) was not received until August 18, 2021. This means that more than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on February 26, 2020.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for myocardial perfusion imaging, tomographic (SPECT) (78452) provided on November 20, 2020 by an out-of-network (OON) provider.  You asked the Plan to pay for the diagnostic service. You say that the medical records provided support the necessity of the services in dispute. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.  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 myocardial perfusion imaging, tomographic (SPECT) (78452) provided on November 20, 2020 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 27, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were not authorized.  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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the services provided by an out-of-network provider on April 27, 2021.
Appeal type: Home Health
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve 2 home health skilled nursing visits.  You asked the Plan to pre-approve 2 home health skilled nursing visits. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has 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 2 home health skilled nursing visits. Our reviewer says that the services are not medically necessary. Our physician reviewer found the review indicates that the records do not show that skilled nursing services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's condition, or to establish/perform a maintenance program to maintain the enrollee's condition and/or prevent deterioration. The records do not show that skilled therapy services are required to effectively provide treatment, care, and/or services in order to improve the enrollee's level of function, or to establish/perform a maintenance program to maintain the enrollee's level of function and/or prevent deterioration.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of 2 home health skilled nursing visits have not been met. Therefore, we decided that the Plan does not have to pre-approve 2 home health skilled nursing visits.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (81455) provided May 3, 2021.  You asked the Plan to pay for the lab services. You say that the services were medically necessary. The Plan denied your request. The Plan says this service is not covered under Medicare rules.  The Plan must follow Medicare rules. Medicare rules say that genetic testing procedures submitted with code 81455 are unlikely to impact therapeutic decision-making in the clinical management of the patient and will be denied automatically as not medically necessary and screening testing.       We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the lab services have not been met. Therefore, we decided that the Plan does not have to pay for lab services (81455) provided May 3, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 2, 2021.  You asked the Plan to pay for a limited oral evaluation. You say that you want the Plan to reconsider. The Plan denied your request. The Plan says the service at issue is not a covered benefit.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140) provided on June 2, 2021.
Appeal type: Surgery
Decision: Favorable

 We decided that the Plan has to pay for tumor excision (21012) procedure provided on February 12, 2021.  You asked the Plan to pay for tumor excision. You say that you are appealing with records. The Plan denied your request. The Plan says that the denial of payment for this service is correct, because the documentation does not support the code 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 21012 is excision, tumor, soft tissue of face or scalp, subcutaneous, 2 centimeters or greater.  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 tumor excision. Our reviewer says that this code meets the criteria for payment. Our reviewer found the record indicates that the enrollee underwent a procedure. The record indicated that the lesion was a squamous cell carcinoma that was greater than 2 centimeters according to the operative note.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of tumor excision have been met. Therefore, we decided that the Plan has to pay for tumor excision (21012) procedure provided on February 12, 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: 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 for muscle weakness and kidney failure. The Plan denied your request. The Plan says that you do not need three hours a day of therapy and your medical illnesses are stable and do not need a physician to monitor them three times a week.  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.  The complexity of your nursing, medical and rehabilitation needs do not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for rhabdomyolysis, acute renal failure requiring hemodialysis, and metabolic acidosis. Your medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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. Our physician reviewer found that your condition does not meet Medicare criteria for IRF 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 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: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for lab services (87631) provided August 5, 2021.  You asked the Plan to pay for the lab services. You say that the lab services were medically necessary. The Plan denied your request. The Plan says this service was for screening purposes and is non-covered.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for lab services (87631) provided August 5, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical services rendered on January 8, 2021 to January 10, 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 38724 is an inpatient-only code.  The Plan must follow Medicare rules. Medicare rules say that inpatient only procedures are not payable at the outpatient level of care.  We looked at the file and Medicare rules. The file shows that billed procedure code 38724 (cervical lymphadenectomy [modified radical neck dissection]) is an inpatient-only code and was billed at an outpatient authorization. Therefore, we decided that the Plan does not have to pay for the surgical services rendered on January 8, 2021 to January 10, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit rendered on July 15, 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 were rendered by an opt-out provider.  The Plan must follow Medicare rules. The rules say that no Medicare payment may be made to a beneficiary for items or services provided directly by a physician or practitioner who has opted out of the program except in cases involving emergencies or urgently needed care.  The services at issue in this appeal were provided in a non-urgent, non-emergent situation by the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visit rendered on July 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 requested admission to an IRF is medically necessary. The Plan denied your request. The Plan says the requested admission to an IRF does not meet criteria.

The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.

We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the enrollee does require physical therapy and occupational therapy services but based on the medical records provided the enrollee does not require an intensive inpatient rehabilitation therapy program. The enrollee will not be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an inpatient rehabilitation facility. Care at the skilled nursing facility level appears to be appropriate in this case. 

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: Unfavorable

 We decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on July 19, 2021.  You asked the Plan to pay for this service. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the service was rendered by an out of network provider, without prior authorization.  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 provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the service at issue in this appeal. The Plan did not pre-approve the service at issue. We found no exception that would require the Plan to pay for this service. Therefore, we decided that the Plan does not have to pay for the domiciliary or rest home visit (99335) rendered by the out-of-network (OON) provider on July 19, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an intraoral complete series of radiographic images (D0210) provided on May 28, 2021.  You asked the Plan to pay for a comprehensive oral evaluation and an intraoral complete series of radiographic images. You say that you do not agree with the denial of the claim. You also say you are unable to pay the amount owed. The Plan denied your request. The Plan says you have exhausted your maximum benefit for these services.  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. The Plan covers a comprehensive oral evaluation every 6 months with a maximum of 2 exams every year and an intraoral complete series of radiographic images once every year.   We looked at the file and Medicare rules. The records show that you received a comprehensive oral evaluation on February 24, 2021 and April 12, 2021. The records also show that you received an intraoral complete series radiographic images on April 12, 2021. Therefore, you have exhausted your maximum benefit for the calendar year for both services. Based on this information, we decided that the Plan's rules for coverage of a comprehensive oral evaluation and intraoral complete series of radiographic images have not been met. Therefore, we decided that the Plan does not have to pay for a comprehensive oral evaluation (D0150) and an intraoral complete series of radiographic images (D0210) provided on May 28, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pay for skilled nursing facility (SNF) care.  You asked the Plan to pay for SNF care. You say that please review the enclosed records and remit payment in full for services provided. The Plan denied your request. The Plan says that the medical necessity criteria for SNF level of coverage were not met.  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 SNF care. Our reviewer says that the enrollee does meet the Medicare criteria for skilled nursing facility services Our physician reviewer found based on the medical records provided this enrollee required skilled nursing services from 04/01/2021 through 04/28/2021 for administration of daily intravenous antibiotics via the PICC line. The enrollee does have skilled therapy service needs and required skilled therapy on a daily basis. The enrollee meets 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 SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pay for skilled nursing facility (SNF) care.   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.