Persius/hicric huggingface dataset:
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pay for the Skilled Nursing Facility (SNF) services provided on October 2, 2020, through October 26, 2020 and billed with Patient Driven Payment Model (PDPM) code FDUF1 x 24 days.  You asked the Plan to pay for the SNF services billed with PDPM code FDUF1 x 24 days. You say that you would like reconsideration because the documentation supports the PDPM code billed. The Plan denied your request. The Plan says that the Minimum Data Set Section GG Clarification note does not identify the 3 day observation period for assessment of the Section GG activities as days 1-3 of the skilled stay and it cannot be used to support assessment coding.  The Plan must follow Medicare rules. Medicare rules say that all SNF Part A inpatient services are paid under a prospective payment system (PPS). This involves payment based on a Health Insurance Prospective Payment System (HIPPS) rate code.   We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the SNF services billed with PDPM code FDUF1 x 24 days have been met. Specifically, the Clarification note is specifically indicated for the admission or days 1 through 3. This note may be used and supports the PDPM code billed on this claim. Therefore, we decided that the Plan has to pay for the Skilled Nursing Facility (SNF) services provided on October 2, 2020, through October 26, 2020 and billed with Patient Driven Payment Model (PDPM) code FDUF1 x 24 days.   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 anesthesia for extensive spine and spinal cord procedures (00670) provided on January 19, 2022.  You asked the Plan to pay for the anesthesia for extensive spine and spinal cord procedures. You say that you would like this claim reprocessed based on the medical documentation provided. The Plan denied your request. The Plan says the service that was coded is not supported by the medical records submitted.  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 00670 is anesthesia for extensive spine and spinal cord procedures (eg, spinal instrumentation or vascular procedures).  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 anesthesia for extensive spine and spinal cord procedures. Our reviewer says that the documentation does not support the services as billed.  Our reviewer found the documentation submitted includes a one page anesthesia record with a surgical procedure that is eligible to confirm the procedure in which anesthesia services were provided.  However, the documentation states "right arthrodesis sacroiliac joint" was performed. Anesthesia for extensive spine and spinal cord would not be reported for procedure on pelvis and lower spine. Therefore, this procedure would not be covered as billed.  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 anesthesia for extensive spine and spinal cord procedures have not been met. Therefore, we decided that the Plan does not have to pay for the anesthesia for extensive spine and spinal cord procedures (00670) provided on January 19, 2022.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy (CPT code 81518), for the enrollee.  You asked the Plan to pre-approve the service. You say that this service will be beneficial for the long-term care of the enrollee. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee's records show they have HER receptor positivity, and they were treated with Herceptin.  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 service. physician reviewer found the Breast Cancer Index (BCI) is a multigene assay used to determine the benefit of prolonged endocrine therapy. It is indicated for patient that ER/PR positive and HER2 negative. This patient is HER2 positive and the use of BCI would not be indicated. The service is not reasonable or medically necessary.  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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve oncology (breast), mRNA, gene expression profiling by real-time RT-PCR of 11 genes (7 content and 4 housekeeping), utilizing formalin-fixed paraffin-embedded tissue, algorithms reported as percentage risk for metastatic recurrence and likelihood of benefit from extended endocrine therapy (CPT code 81518), for the enrollee.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the diagnostic radiology services provided on August 10, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the OON services. You say that you are requesting retro authorization. The Plan denied your request. The Plan says the services were not urgent, emergent, or 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 file shows that a screening mammogram and breast tomosynthesis was provided. The 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 diagnostic radiology services provided on August 10, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the seat lift provided on September 4, 2021.  You asked the Plan to pay for the seat lift. You say that this was medically necessary. The Plan denied your request. The Plan says that you do not meet medical necessity criteria for a seat lift.  The Plan must follow Medicare rules. The rules say that a seat lift mechanism is covered if all of the conditions listed in the Medicare rules section are met.  We looked at the file and Medicare rules. The records from the skilled nursing facility indicate you were able to stand up by yourself. There are also no records indicating you have severe arthritis of the hip or knee or have a severe neuromuscular disease.       Based on this information, we decided that Medicare rules for coverage of the seat lift have not been met. Therefore, we decided that the Plan does not have to pay for the seat lift provided on September 4, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for laboratory services (87205, 87070, 87075) provided on July 1, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay for laboratory services. You say that the patient was seen by a facility/physician that is in-network. You also say that there was not an in-network laboratory or any alternative to be used who could offer the appropriate medical treatment needed for the patient's care. You also say that the patient had no control over the location in which their specimen was sent for processing. The Plan denied your request. The Plan says this provider is out-of-network and the member was referred to this provider by an out-of-network provider. The Plan also says that authorization was not obtained prior to the services being rendered and it was determined the services were not urgent or emergent in nature.  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 laboratory services (87205, 87070, 87075) provided on July 1, 2021 by an out-of-network (OON) provider.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 3, 2021, through June 4, 2021.  You asked the Plan to pay for acute inpatient hospital care. The Plan denied your request. The Plan says the care could have been provided at a lower level.  The Plan must follow Medicare rules. The rules say that inpatient hospital care is covered when the doctor expects the patient to need hospital care that crosses at least two midnights. In rare and unusual cases, consideration may be given to inpatient hospital care when the hospital stay does not cross two midnights or more.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for acute inpatient hospital care. Our reviewer says that the documentation does not support that the criteria for inpatient payment are met in this case. Our physician reviewer found the review has determined that the record did not show that at the time of inpatient admission the admitting physician reasonably expected that the enrollee's necessary hospital care (including earlier emergency department and/or observation care) would span two midnights.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of acute inpatient hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the acute inpatient hospital care provided from June 3, 2021, through  June 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (E2311), harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware (E2313), and power seat elevation system (E2300), for the enrollee.  You asked the Plan to pre-approve the DME. You say that the DME is necessary. The Plan denied your request. The Plan says the DME is not necessary.  The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the DME have not been met. The seat lift does not serve a primary medical purpose. The upgraded electronics (expandable controller, harness and electronic connector to 2 power options) are not medically necessary. They are necessary when there is a medical need to control power options though the joystick. The notes do not show a medical need to control the power options through the joystick. The power options can be controlled using their own switches. These switches can be made any size without asking for a separate request. They can be made from any material without asking for a separate request. All of this can be done without the need to use the joystick to control the power features. Therefore, we decided that the Plan does not have to pre-approve expandable controller, including all related electronics and mounting hardware, upgrade provided at initial issue (CPT code E2377), electronic connection between wheelchair controller and two or more power seating system motors, including all related electronics, indicator feature, mechanical function selection switch, and fixed mounting hardware (E2311), harness for upgrade to expandable controller, including all fasteners, connectors and mounting hardware (E2313), and power seat elevation system (E2300), for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient mental health care provided on April 25 to May 13, 2021.  You asked the Plan to waive the copayment for inpatient mental health care. You say that your care was very poor and you are therefore denying payment of the bill. The Plan denied your request. The Plan says the correct copayment was applied.  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 $250 copayment for each day of days 1 to 7 per inpatient admission.   You have been asked to pay $1,750, or a $250 copayment for each day of days 1 to 7 of an inpatient stay for inpatient mental health care. 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. Health plans are not required to waive this cost sharing when there is dissatisfaction with the quality of care received. Therefore, we decided that the Plan does not have to waive the copayment for inpatient mental health care provided on April 25 to May 13, 2021.   Maximus Federal Services read your letter and knows that you may have a quality of care concern. Maximus Federal Services cannot address quality of care issues. We are forwarding your quality of care concern to the appropriate Quality Improvement Organization for further review.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for an emergency room (ER) visit provided on August 9, 2021.  You asked the Plan to waive the copayment for the ER visit. You say that you feel that your doctor forced and pressured you to go to the emergency room for your swollen ankles. The Plan denied your request. The Plan says you have been charged 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 $65 copayment for each emergency room visit.      You have been asked to pay a $65 copayment for the ER visit. the ER visit falls within the Emergency Care 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 an emergency room (ER) visit provided on August 9, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 10, 2020.  You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says the denied codes remain not supported.  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 denied codes are not supported in the medical record. Specifically, the place of service on the CMS-1500 form must reflect the location of the patient when the specimen was obtained. The claim reflects a place of service (POS) for a laboratory (POS 81), while the records reflect of place of service of a nursing facility (POS 32). Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pay for laboratory services provided to the enrollee on August 10, 2020.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the simple extractions (D7140) and surgical extractions (D7210).  You asked the Plan to pre-approve the extractions. You say that you feel you do not have a choice but to be put to sleep for this procedure. The Plan denied your request. The Plan says the dental pre-treatment estimate claim was processed correctly according to your plan benefits. The Plan also says that the Plan cannot pay more than the $862.18 remaining on your Plan's 2021 dental benefits.  Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds Medicare coverage. For that reason, the Plan's coverage rules apply in this case.  Though the Plan offers a dental benefit in excess of Medicare coverage, the record shows that at the time of the request you only had $862.18 of your annual $1,100 dental allowance left available. The amount of $862.18 will exhaust your annual dental allowance for the 2021 benefit year. Therefore, we decided that the Plan does not have to pre-approve the simple extractions (D7140) and surgical extractions (D7210).   Please Note: If you have not already received these services at issue, you may wish to make a new request under your 2022 benefits.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.  You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says unproven and not medically necessary procedures are not covered by Medicare due to insufficient evidence of efficacy.  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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy.  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 service have not been met. Therefore, we decided that the Plan does not have to pre-approve the Vertiflex superion device placement surgery (CPT code 22869), for the enrollee.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay in full for the maxillary partial denture (D5213) provided on June 25, 2021 by an out-of-network (OON) provider.  You asked the Plan to pay in full for the maxillary partial denture. You say that you believe the Plan should pay 100% for this service. The Plan denied your request. The Plan says you are responsible for the difference between the in-network fee schedule and the dentist's charged fees when visiting an OON dentist. The Plan also says that when you contacted the Plan on May 21, 2021 you were advised that if you utilized an OON provider the services are paid at 100% of the maximum allowable fee.  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, you are responsible for the difference between the billed amount and the allowed amount because this service was received OON. Therefore, we decided that the Plan does not have to pay in full for the maxillary partial denture (D5213) provided on June 25, 2021 by an out-of-network (OON) provider.
Appeal type: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the testing services rendered on May 25, 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 95908 is not supported.
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 95908 is nerve conduction studies; 3-4 studies. We find that CPT code 95908 is not supported in the medical record. Specifically, there is no documentation of 3-4 nerve conduction studies. 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 pay for the testing services rendered on May 25, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the lesion destruction (68135) provided on March 11, 2021.  You asked the Plan to pay for the lesion destruction (68135). You say that the CPT code was billed with modifier 59 to override any claim edits. You say that the medical notes support the billing, and the claim should be reprocessed for payment. The Plan denied your request. The Plan says CPT code 68135 is included in CPT code 68115 and cannot be separately reimbursed.  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 lesion destruction (68135). Our reviewer says that the documentation submitted was reviewed and does not meet the criteria for coverage. Our reviewer found that the procedure report describes procedures performed on the right eye through the same incision, and therefore does not support a separate procedure performed in a different anatomical site or that a separate encounter was performed. In this case, CPT 68135 would be inclusive to the primary service billed.   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 lesion destruction (68135) have not been met. Therefore, we decided that the Plan does not have to pay for the lesion destruction (68135) provided on March 11, 2021.