Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from April 1, 2019 to April 14, 2019.
You asked the Plan to pay for the skilled nursing facility (SNF) services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says that the services billed are not supported by the documentation.
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 skilled nursing facility services provided with RUB20 x2 days & RVB0D x 12days. The Plan has stated that the RUB20 for two days was supported by the documentation. 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 skilled nursing facility (SNF) services. Our reviewer says that the documentation supports the services billed. Our physician reviewer found the documentation supports the enrollee coding of extensive assist for bed mobility and toileting, and at least 1 episode requiring 2 staff members for transfers. This means the case file supports RUB20 for 2 days and RVB0D for 12 days. Therefore, the RUG score billed is supported by the documentation. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do substantiate the DRG as billed. Therefore, we decided that the Plan has to pay for the skilled nursing facility (SNF) services provided from April 1, 2019 to April 14, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for debridement, subcutaneous tissue (11042) provided on June 9, 2021 by an out-of-network (OON) provider.
You asked the Plan to pay for the wound care services. You say that you have enclosed supporting documentation. Please review records and reconsider your claim for payment. 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 debridement, subcutaneous tissue (11042) provided on June 9, 2021 by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for a hereditary cardiovascular screening (81407, 81408, 81410, 81411) provided on March 22, 2021.
You asked the Plan to pay for a hereditary cardiovascular screening. You say that these services have been paid by Medicare in the past. The Plan denied your request. The Plan says this is not covered.
The Plan must follow Medicare rules. Medicare rules say that Medicare denies coverage for all cardiovascular (CV) risk assessment panels, except the basic lipid panel, for symptomatic and asymptomatic patients. We looked at the file and Medicare rules. The services at issue are a CV risk assessment panel and are not covered.
Based on this information, we decided that Medicare rules for coverage of a hereditary cardiovascular screening have not been met. Therefore, we decided that the Plan does not have to pay for a hereditary cardiovascular screening (81407, 81408, 81410, 81411) provided on March 22, 2021
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute inpatient hospital care to be provided in conjunction with a knee replacement surgery.
You asked the Plan to pre-approve acute inpatient hospital care. You say that you anticipate a slow recovery and you cannot go ahead with your necessary surgery without being approved for the hospital stay as well. The Plan denied your request. The Plan says they have agreed to approve the knee joint replacement surgery (0055T, 27447); however, the associated inpatient hospital stay is not medically necessary with this procedure.
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 pre-approve acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient care are met in this case. Our physician reviewer found a request was made for inpatient admission in conjunction with a planned elective and non-emergent total knee arthroplasty procedure. Your medical history is significant for sleep apnea. Although sleep apnea can affect the duration of recovery for some individuals, there is no evidence that there would be an expected delayed recovery or complication during the surgery to justify the requested inpatient services. There is no expectation that you would require hospital services that would likely cross two midnights. Re-evaluation following surgery can be made for inpatient surgery if the services are found to be necessary at that time. 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 pre-approve acute inpatient hospital care to be provided in conjunction with a knee replacement surgery.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pay for the skilled nursing services provided from May 21, 2021, to June 2, 2021.

You asked the Plan to pay for the skilled nursing services. You say that the services which the enrollee required and received are coverable under the Medicare Act. The Plan denied your request. The Plan says the enrollee's condition no longer required daily skilled services at an inpatient Skilled Nursing Facility (SNF) level of care.

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 the skilled nursing services. Our reviewer says that the enrollee did not meet the Medicare criteria for SNF care. Our physician reviewer found the enrollee did not have daily skilled nursing needs that required the specialized skill, knowledge, and judgment of a skilled professional nurse. The enrollee did not have daily skilled therapy needs that required the specialized skill, knowledge, and judgment of a skilled professional therapist. The enrollee did not require daily skilled nursing and/or skilled therapy on an inpatient basis in a SNF 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 the skilled nursing services have not been met. Therefore, we decided that the Plan does not have to pay for the skilled nursing services provided from May 21, 2021, to June 2, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an out-of-network referral for cardiac rehabilitation.
You asked the Plan to pre-approve the referral. You say that this is medically necessary. The Plan denied your request. The Plan says the requested services are available in-network.
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 an out-of-network referral for cardiac rehabilitation.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Freestyle libre 14-day sensor KIT, for the enrollee.
You asked the Plan to pre-approve the sensor. You say that the enrollee is currently using Lantus insulin once daily at bedtime and no other insulin. The Plan denied your request. The Plan says the Medicare rules have not been met.
The Plan must follow Medicare rules. Medicare rules say that therapeutic CGMs are considered medically reasonable and necessary for enrollees with diabetes who use insulin with at least three daily administrations, require frequent self-adjustment of insulin dosage based on the blood glucose testing results and have had an in-person visit with their treating physician to assess adherence to their CGM regimen and diabetes treatment plan.
We looked at the file and Medicare rules. The documentation indicates that the enrollee does not perform blood glucose testing at least four times per day, use insulin with at least three daily injections, require frequent self-adjustment of insulin dosage based on the blood glucose testing results, have had an in-person visit with their treating physician to assesses adherence to their CGM regimen and diabetes treatment plan. Based on this information, we decided that Medicare rules for coverage of the sensor have not been met. Therefore, we decided that the Plan does not have to pre-approve Freestyle libre 14-day sensor KIT, for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic manipulative treatment (98941) rendered by the out-of-network (OON) provider on June 2, 2020.
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 chiropractic manipulative treatment (98941) rendered by the out-of-network (OON) provider on June 2, 2020.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve treatment with Dupixent pen.
You asked the Plan to pre-approve Dupixent pen. You say that the requested drug is a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for self-administered drugs have not been met.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drug requested here is not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve treatment with Dupixent pen.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continuation of inpatient mental health care provided to
the enrollee from October 21, 2021, forward.
You asked the Plan to pre-approve inpatient mental health care. You say that the enrollee is still in need of
treatment at an inpatient level. The Plan denied your request. The Plan says the stay is not medically necessary.
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 mental health care. Our
physician reviewer found the enrollee does not meet the criteria for treatment in an acute inpatient mental
health treatment beyond the date in question of October 22, 2021, forward, and could have been treated in a
lesser restrictive setting as the enrollee was not showing any suicidal or homicidal ideation, auditory or visual
hallucinations and was not showing any aggressive behaviors being cooperative and compliant.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient mental health care have not been met. Therefore, we decided that the
Plan does not have to pre-approve continuation of inpatient mental health care provided to the enrollee from
October 21, 2021, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy services (90832) provided March 31, 2021.
You asked the Plan to pay for the psychotherapy services. You say that claim denied for service not medically necessary. Please see enclosed medical records for review and reconsideration of payment for this claim. The Plan denied your request. The Plan says there was no documentation of consultation with the attending or primary care physician in the medical record.
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically necessary are not covered.
We looked at the file and Medicare rules. The submitted claim does not include a referring provider for the services at issue. Documentation of a physician consultation does not apply when the physician has referred the beneficiary to the clinical psychologist. Based on this information, we decided that Medicare rules for coverage of the psychotherapy services have not been met. Therefore, we decided that the Plan does not have to pay for individual psychotherapy services (90832) provided March 31, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a maxillary partial denture (D5213) and mandibular partial denture (D5214).
You asked the Plan to pre-approve the partial dentures. You say that you were not aware of your coverage and would like these services to be reconsidered. The Plan denied your request. The Plan says these services are not covered. The Plan also says that you are not enrolled in the optional supplemental 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 pre-approve a maxillary partial denture (D5213) and mandibular partial denture (D5214).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the drug services received from April 2, 2021 to April 30, 2021.
You asked the Plan to pay for the drug services. You say that you would like the plan to reconsider their denial. 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. We find that the drug services are not supported in the medical record. Specifically, these services were not billed with the required modifier for end stage renal disease (ESRD). The Plan has noted that a corrected claim should be submitted with the required modifier for reconsideration. Based on this information, we decided that Medicare rules for coverage of the drug services have not been met.
Therefore, we decided that the Plan does not have to pay for the drug services received from April 2, 2021 to April 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.

You asked the Plan to pre-approve the device. You say that this is medically necessary. The Plan denied your request. The Plan says this is considered experimental and investigational and is not being given as part of a Medicare-covered clinical trial.

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 device. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found this device is experimental. More research is needed to show safety and efficacy of the device. 

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 device have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex device for the enrollee.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for electrocardiogram, routine ECG with at least 12 leads;
interpretation and report only (CPT code 93010) and service(s) provided between 10:00 PM and 8:00 AM at
24-hour facility, in addition to basic service (CPT code 99053) provided to the enrollee on February 22, 2021.
You asked the Plan to pay for the services. You say that the claim should be paid. 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.
Our records indicate a National Correct Coding Initiatives (NCCI) Procedure to Procedure (PTP) edit exists
between 93010 and 31500. This PTP edit has a modifier indicator of 1, which indicates modifiers associated
with NCCI are allowed, however, an appropriate NCCI modifier was not billed with this PTP code edit. We are
also upholding CPT code 99053, which has a status indicator of 'B' on the Centers for Medicare & Medicaid
Services (CMS) Physician Relative Value File, and is always bundled into payment for other services not
specified and no separate payment is made per Medicare. Therefore, we decided that the Plan does not have to
pay for electrocardiogram, routine ECG with at least 12 leads; interpretation and report only (CPT code 93010)
and service(s) provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (CPT
code 99053) provided to the enrollee on February 22, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for multiplex PCR respiratory viral panel testing provided on December 3, 2020.
You asked the Plan to pay for respiratory viral panel testing. You say that this testing was ordered by a treating physician who makes the professional determination of medical necessity. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because multiplex PCR respiratory viral panel testing of 6 or more targets is not covered by Medicare.
The Plan must follow Medicare rules. Medicare rules say that multiplex PCR respiratory viral panels of 6 or more targets are non-covered. We looked at the file and Medicare rules. This testing for 6 or more targets is not covered by Medicare. Based on this information, we decided that Medicare rules for coverage of respiratory viral panel testing have not been met. Therefore, we decided that the Plan does not have to pay for multiplex PCR respiratory viral panel testing provided on December 3, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 13, 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. Medicare rules say that providers must report services correctly. 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 81479. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 13, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on March 24, 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 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 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 March 24, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay an additional amount for eyeglasses provided on June 23, 2021.

You asked the Plan to pay an additional amount for eyeglasses. You say that you believe the Plan should have paid more toward the purchase of your eyeglasses. The Plan denied your request. The Plan says this claim was processed correctly per the in-network benefits.

Medicare generally does not cover routine eyewear services. However, the Plan offers a routine eyewear benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 

We looked at the file and the Plan's rules. The file shows that the Plan paid the maximum benefit of $300 for the purchase of the eyeglasses. Therefore, we decided that the Plan does not have to pay an additional amount for eyeglasses provided on June 23, 2021.