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

 We decided that the Plan does not have to pay for the ultrasound provided on October 27, 2020, by an out-of-network (OON) provider.  You asked the Plan to pay for the ultrasound. You say that you are appealing this denial. The Plan denied your request. The Plan says no prior authorization was obtained.  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 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 ultrasound provided on October 27, 2020, by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the outpatient office visit (99205) psychiatric diagnostic evaluation (90792) to be provided by an out-of-network (OON) provider.  
You asked the Plan to pre-approve the outpatient services. You say that you are in a lot of pain and the requested services are medically necessary. 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 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 items/services at issue in this appeal. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve the outpatient office visit (99205) psychiatric diagnostic evaluation (90792) to be provided by an out-of-network (OON) provider.
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 is not medically necessary.  
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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the chiropractic services provided on March 27, 2021.  You asked the Plan to pay for the services provided. You say that you suffer from severe pack pain. The Plan denied your request. The Plan says the services are excluded from coverage.  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 file shows that an office visit and x-rays were provided. We looked at the file and the rules. The records show that the services at issue are not manual manipulation of the spine. Services other than manual manipulation, when provided by a chiropractor, are not a covered benefit. Therefore, we decided that the Plan does not have to pay for the chiropractic services provided on March 27, 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 is not medically necessary.  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 complexity of the enrollee's nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the breast biopsy services provided June 30, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the breast biopsy services. You say that you would like this claim reprocessed and approved for payment. The Plan denied your request. The Plan says documentation was not provided to determine how the member came to the servicing provider or whether the services were medically necessary.  The Plan must follow Medicare rules. The rules say that the provider, supplier, or beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Specifically, there were no medical records provided in this case. Without the medical records, we cannot review to see if the services were urgent/emergent or medically necessary. Therefore, we decided that the Plan does not have to pay for the breast biopsy services provided June 30, 2021, by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) (CPT code 63048 X2) provided to the enrollee on July 8, 2021.  
You asked the Plan to pay for the service. You say that the claim should be paid. The Plan denied your request. The Plan says the services are not supported by the records.  
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 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 service. Our reviewer found CPT code 63048 X2 - laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) provided on July 8, 2021, does not meet criteria for billing or reimbursement consideration. 
The medical records provided does not include sufficient documentation to validate that 63048 X2 was performed as distinct/separate procedures on July 8, 2021. CPT 63048 X2 is bundled with CPT code 22633 which was performed on July 8, 2021 during the same operative session. A modifier can be used to unbundle these services providing the medical records support the use of the modifier, therefore, the is no separate reimbursement for 63048 X2.  
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 service have not been met. Therefore, we decided that the Plan does not have to pay for laminectomy, facetectomy and foraminotomy (unilateral or bilateral with decompression of spinal cord, cauda equina and/or nerve root[s], [eg, spinal or lateral recess stenosis]), single vertebral segment; each additional segment, cervical, thoracic, or lumbar (List separately in addition to code for primary procedure) (CPT code 63048 X2) provided to the enrollee on July 8, 2021.
Appeal type: Imaging
Decision: Favorable

 We decided that the Plan has to pre-approve a Magnetic Resonance Cholangiopancreatography (MRCP) (S8037).  You asked the Plan to pre-approve a MRCP. You say that the service at issue is medically necessary. The Plan denied your request. The Plan says that a similar service has been approved and is therefore, not medically necessary.  The Plan must follow Medicare rules. Medicare rules say that MRIs are covered only when they are medically 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 a MRCP. Our reviewer says that the enrollee meets criteria for coverage of the MRCP. Our physician reviewer found the record shows the approved MRI of the abdomen has a signed report in the records and is dated November 29, 2021. The recommended MRCP should be approved as a study for further evaluation of an area of concern on that MRI. A new and separate procedure, MRCP should be approved as appropriate.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of a MRCP have not been met. Therefore, we decided that the Plan has to pre-approve a Magnetic Resonance Cholangiopancreatography (MRCP) (S8037).   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 debridement services provided on September 8, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the debridement services. You say that the services were medically necessary. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the debridement services provided on September 8, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a home mechanical ventilator for the enrollee.  You asked the Plan to pre-approve the ventilator. You say that this is medically necessary. The Plan denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured pressure support (AVAPS) move that could be delivered by bilateral positive airway pressure (BiPAP) is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 ventilator. Our reviewer says that the requested ventilator is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has chronic respiratory failure from chronic obstructive pulmonary disease. The record indicates that the enrollee is ordered BiPAP with AVAPS setting. The provided primary source documentation does not contain sufficient detailed information in the medical record to justify the treatment modality selected. The enrollee could be treated with a BiPAP machine with AVAPS capability. The elements of the coverage criteria are not satisfied.  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 ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a home mechanical ventilator for the enrollee.
Appeal type: Other
Decision: Unfavorable

We decided that the Plan does not have to pre-approve radio frequency ablation (RFA) of the lumbar spine.  
You asked the Plan to pre-approve RFA of the lumbar spine. You say that you do not want to repeat the initial series of shots and would like the RFA services without them. The Plan denied your request. The Plan says the criteria for coverage have not been met for the requested services.  The Plan must follow Medicare rules. Medicare rules say that if an extended period of time has passed since the last RFA procedure, the initial diagnostic procedures must be repeated.  We looked at the file and Medicare rules. In this case, the last RFA procedure was performed in April 2019. Since more than 2 years have passed, the initial diagnostic procedures must be required. Based on this information, we decided that Medicare rules for coverage of RFA of the lumbar spine have not been met. Therefore, we decided that the Plan does not have to pre-approve radio frequency ablation (RFA) of the lumbar spine.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to reduce the copayment for the nuclear medicine study provided on September 21, 2021.  You asked the Plan to reduce the copayment for the nuclear medicine study. You say that you were never informed of the cost of the test. You say you paid $50 at the time of the visit and should not be responsible for the additional $125 copayment. The Plan denied your request. The Plan says you have been asked to pay the correct cost-sharing amount.  
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 $225 copayment for each Medicare-covered advanced radiology service.   
You have been asked to pay a $225 copayment for the nuclear medicine study. The nuclear medicine study falls within the "Outpatient diagnostic tests and therapeutic services and supplies" benefit category. The record shows the nuclear medicine study is considered an advanced radiology service. 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 reduce the copayment for the nuclear medicine study provided on September 21, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the office visit provided on January 19, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says they cannot issue payment for services from an opt-out physician.  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 a provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for the office visit provided on January 19, 2021.
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 requested admission to a LTACH is medically necessary. The Plan denied your request. The Plan says the requested admission to a LTACH does not meet criteria.  
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 appears to be unstable and worsening and requires short-term additional acute care services that can be safely completed at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility.  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 anesthesia services provided on March 25, 2021.  You asked the Plan to pay for the services provided. The Plan denied your request. The Plan says no separate payment is made.  
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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). We find that CPT code 99100 is a bundled code. 
When these services are covered, payment for them is subsumed by the payment for the services to which they are incident. Based on this information, we decided that Medicare rules for coverage of the services provided have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia services provided on March 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the removal of nail plate (11730-59) provided on April 22, 2021.  You asked the Plan to pay for the removal of nail plate. You say that you would like this claim reprocessed based on the medical records. The Plan denied your request. The Plan says the second unit billed of this service is not eligible for payment as multiple submissions for a single date of service are not warranted in this case.  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 11730 is avulsion of nail plate, partial or complete, simple; single.  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 removal of nail plate. Our reviewer says that the documentation does not support the services as billed. Our reviewer found the medical records provided do not include sufficient to support billing 11730-59 for date of service April 22, 2021. Specifically, "The primary code 11730 has a Medicare Unlikely Edit (MUE) of 1 and +11732 has an MUE of 9, so the codes are already set up to count individual nail plates up to 10. If 5 are removed, then you'd have 11730, 11732 x 4. If all 10 toes had nail plate avulsions, then it'd be 11730, 11732 x 9." Therefore, the billing of 11730 with the -59 modifier would be considered improper coding.  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 removal of nail plate have not been met. Therefore, we decided that the Plan does not have to pay for the removal of nail plate (11730-59) provided on April 22, 2021.