Persius/hicric huggingface dataset:
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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH 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 the enrollee is receiving acute hospital care, and acute care services have not been denied. The documentation does not support that the enrollee in this case requires services at the LTACH that are not available at the acute care hospital where he is currently receiving care. The documentation does not support that an additional 25 days of hospitalization are reasonably expected for the enrollee 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 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: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the Coronavirus laboratory test (U0002) and the fluoroscopic guidance services (77002) provided on June 28, 2021.
You asked the Plan to pay for codes U0002 and 77002. 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. Providers must report services with the appropriate CPT code. In this case, the CPT Code Manual definition of code U0002 is 2019-ncov coronavirus, sars-cov-2/2019-ncov (covid-19), any technique, multiple types or subtypes (includes all targets), non-cdc. We find that Healthcare Common Procedure Coding System (HCPCS) code U0002 is not supported in the medical record. Specifically, HCPCS code U0002 was billed on the same claim as CPT code 87635. The record shows that CPT code 87635 for Coronavirus testing was previously processed and paid by the Plan. It is not appropriate to report the HCPCS code and CPT code for Coronavirus testing on the same claim. Furthermore, the definition of code 77002 is Fluoroscopic guidance for needle placement (eg, biopsy, aspiration, injection, localization device) (List separately in addition to code for primary procedure). We find that CPT code 77002 was not billed with a valid primary procedure code.
Therefore, we decided that the Plan does not have to pay for the Coronavirus laboratory test (U0002) and the fluoroscopic guidance services (77002) provided on June 28, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the x-ray represented by code 73560 provided on July 9, 2021.

You asked the Plan to pay for code 73560. 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. 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 73560 is a column II code to column I code 73562. 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 x-ray represented by code 73560 provided on July 9, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the extraction (D7140), periapical x-ray (D0220), and bitewing x-ray (D0270) provided on April 9, 2021.
You asked the Plan to pay for the dental services. You say that the in network providers that you contacted were no longer in network or not at that office. You also say that you were advised the services would be covered. The Plan denied your request. The Plan says the provider in this case is out of network. The Plan says that dental services received out of network are not covered. The Plan also says that you were advised prior to the date of service that only services received in network would be covered.
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, dental services received out of network are not among those covered under this benefit. The record shows that you contacted the plan regarding dental coverage and were advised only services received in network would be covered. The record shows that the representative offered to locate in network dentists but you advised no. Therefore, we decided that the Plan does not have to pay for the extraction (D7140), periapical x-ray (D0220), and bitewing x-ray (D0270) provided on April 9, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Nivolumab for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this drug is not supported for this type of cancer.
The Plan must follow Medicare rules. The rules say that Medicare pays for a drug or biological only if it is safe and effective and otherwise reasonable and necessary. 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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the Medicare-approved compendia do not support the requested drug for myeloma. 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 drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Nivolumab for the enrollee.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for continuation of SNF services provided from
January 23, 2021, through February 21, 2021.
You asked the Plan to pay for continuation of SNF services. The Plan denied your request. The Plan says continuation of SNF services is not medically necessary.
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 continuation of SNF services. Our reviewer says that daily skilled services are not medically necessary. Our physician reviewer found from a nursing perspective; the enrollee received oral medications. The enrollee had stable vital signs. Her appetite was good. Her lungs were clear. She was treated for skin tears. Regarding rehabilitation services, the enrollee received physical therapy and occupational therapy in the SNF. By the dates in question, the enrollee was discharged from skilled therapy and did not receive nor require further services. 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. As a practical matter, this 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 continuation of SNF services have not been met. Therefore, we decided that the Plan does not have to pay for continuation of SNF services provided from January 23, 2021, through
February 21, 2021.
Appeal type: Step-Therapy
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Orencia.
You asked the Plan to pre-approve Orencia. You say that the requested drug is medically necessary. The Plan denied your request. The Plan says step therapy criteria have not been met.
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 Orencia. Our reviewer says that the requested drug is not medically reasonable and necessary. Our physician reviewer found The Plan requires a trial of Humira, Enbrel, Xeljanz, or Rinvoq before they will approve the requested drug. In this case, the patient has not tried and failed the required drug(s). There is no documentation provided indicating that the Plan's required drug(s) would likely be less effective and/or likely 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 Orencia have not been met. Therefore, we decided that the Plan does not have to pre-approve Orencia
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve neurectomy of the regular temporal nerve with segmental ligation of the superficial temporal artery (37609, 64787, 64771).
You asked the Plan to pre-approve these services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the clinical value and effectiveness of neurectomy/neuroplasty in the setting of infrequent Migraine headaches have not been demonstrated in the peer-reviewed literature.
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 these services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. The research and trials that have been done to date on surgical interventions for migraines, including one randomized prospective trials and retrospective analyses that have been performed have had significant methodological flaws and limitations. As a result, the scientific evidence to date does not permit conclusions concerning the effect on health outcome. In as much the procedure remains within the research and experimental stage of the development. Our physician reviewer found that your condition does not meet criteria for coverage of these
services. 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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve neurectomy of the regular temporal nerve with segmental ligation of the superficial temporal artery (37609, 64787, 64771).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from November 7, 2020, to November 10, 2020, and billed with DRG (diagnosis related group) 070.
You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your request. The Plan says the primary diagnosis should be the urinary tract infection.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 070, nonspecific cerebrovascular disorders with major complications or comorbidities. 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 inpatient care. Our reviewer says that the billed DRG is not supported. Our physician reviewer found the records indicate that the patient presented to the emergency room with worsening weakness and lethargy, on admission was found to have a urinary tract infection and pneumonia. The primary diagnosis should be the urinary tract infection. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient care provided from November 7, 2020, to November 10, 2020, and billed with DRG (diagnosis related group) 070.
Appeal type: SNF
Decision: Favorable

We decided that the Plan has to pay for the Skilled Nursing Facility (SNF) services provided on June 5, 2020, through June 30, 2020 at the KDXE1 payment level.
You asked the Plan to pay for the SNF services. You say that you would like reconsideration because the documentation supports the KDXE1 payment level. The Plan denied your request. The Plan says that the documentation provided does not support coding of all Section GG payment items which results in a reduction of the PT/OT and nursing components of the validated PDPM score.
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. Specifically, the Plan's denial rationale is not sufficiently specific to support the denial of the billed case-mix groups at issue. The Plan simply indicates that the functional scores are not supported but does not indicate which functional skills are incorrectly documented, nor what the Plan feels the correct scoring would be for these. The Plan's obligation is to support the alternate case-mix grouping it feels is appropriate for the PT/OT and nursing services. Review of the records provided shows no obvious discrepancy between what is reported in the various evaluations and what is documented in the Minimal Data Set (MDS) assessment. We find that the Plan's denial of the billed PT/OT and nursing case-mix groups is not substantiated. Therefore, we decided that the Plan has to pay for the Skilled Nursing Facility (SNF) services provided on June 5, 2020, through June 30, 2020 at the KDXE1 payment level.
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: Home Health
Decision: Unfavorable

We decided that the Plan does not have to pay for the home health services provided from December 19, 2019 through December 31, 2019.
You asked the Plan to pay for the home health 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.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for the home health services provided from December 19, 2019 through December 31, 2019.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the hearing aid, digital, monaural, bte (V5257) provided
February 4, 2021, by an OON provider.

You asked the Plan to pay for the hearing aids. You say that you want partial reimbursement for the hearing
aids. The Plan denied your request. The Plan says the hearing aids were purchased OON and therefore are not
covered.

Medicare does not pay for hearing aids or related services. However, the Plan offers a hearing aid benefit that
exceeds Medicare coverage. For that reason, the plan's coverage rules apply in this case. The Plan pays for
hearing aids only when purchased from the Plan's specified hearing aid vendor.

We looked at the file and the Plan's rules. 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. Based on this information, we decided that the Plan's rules for coverage of
the hearing aids have not been met. Therefore, we decided that the Plan does not have to pay for the hearing
aid, digital, monaural, bte (V5257) provided February 4, 2021, by an OON provider.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance service, advanced life
support, emergency transport, level 1 (A0427) provided May 22, 2021.
You asked the Plan to waive the copayment for the emergency ambulance service. You say that your agent
assured you the bill would be covered. The Plan denied your request. The Plan says the copayment has been
applied correctly.
The rules say a plan must disclose to its enrollees in clear, accurate terms all cost sharing information (such as
copayments, deductibles and coinsurance). Your contract with the Plan clearly says that you must pay a $300
copayment for each Medicare-covered one-way trip via ground ambulance.
You have been asked to pay a $300 copayment for the emergency ambulance service. The emergency
ambulance service falls within the Ambulance services benefit category. This means that you have been asked
to pay the correct amount based on your contract with the Plan. This cost sharing is a contractual obligation
you agreed to pay when you enrolled in the Plan. Therefore, we decided that the Plan does not have to waive
the copayment for the ambulance service, advanced life support, emergency transport, level 1 (A0427)
provided May 22, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a group 3 power wheelchair.
You asked the Plan to pre-approve the wheelchair. You say that a new power wheelchair is needed, because the old is already damaged. The Plan denied your request. The Plan says there is no qualifying diagnosis causing a mobility limitation for which a group 3 power wheelchair is needed.
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD. 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 wheelchair. Our reviewer says that
the requested wheelchair is not medically reasonable or necessary. Our physician reviewer found the treating medical provider face to face on 7/7/21 states that you are independent for dressing, bathing, toileting, and feeding. You can get out of bed yourself and walk, therefore the documentation does not support that your mobility deficit significantly impairs MRADLs in the home. There is no evidence of being high risk for pressure ulcers, increased tone or spasticity or use of intermittent catheterization therefore the tilt and recline is not medically necessary. Additionally, it is unclear whether your current power wheelchair which is three years old is not working as the documentation is conflicting. The face to face states that you use your chair to get out of the home. This additionally does not support that using the requested power wheelchair will significantly improve MRADLs in the home. Furthermore, the enrollee's mobility deficit does not appear to be due to a myopathy, neurologic disease, or congenital skeletal deformity. The documentation indicates that you had a prior stroke, but the documentation does not fully support that this mobility deficit is related to the stroke. 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 wheelchair have not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 power wheelchair.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency department services (99285) provided on March 31, 2021.

You asked the Plan to pay for the emergency department services. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says the services are not payable 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, the CPT Code Manual definition of code 99285 is emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient's clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of high severity and pose an immediate significant threat to life or physiologic function.

We find that CPT code 99285 is not supported in the medical record. Specifically, this code was billed with a primary/first-listed diagnosis code of T36.95XA (adverse effect of unspecified systemic antibiotic, initial encounter). Certain conditions have both an underlying etiology and multiple body system manifestations due to the underlying etiology. For such conditions, it is required that the underlying condition be sequenced first followed by the manifestation. That means the primary/first-listed diagnosis code is incorrect for this code. Based on this information, we decided that Medicare rules for coverage of the emergency department services have not been met. Therefore, we decided that the Plan does not have to pay for the emergency department services (99285) provided on March 31, 2021.