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

 We decided that the Plan does not have to pay for the office visit and lab services (84550, 99212) provided on April 22, 2021, while out of the country.  You asked the Plan to pay for the office visit and lab services. You say that you would like this claim reimbursed by the Plan. The Plan denied your request. The Plan says documentation is missing that is necessary for this to be processed.  The Plan must follow Medicare rules. Medicare 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. 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. Based on this information, we decided that Medicare rules for coverage of the office visit and lab services have not been met. Therefore, we decided that the Plan does not have to pay for the office visit and lab services (84550, 99212) provided on April 22, 2021, while out of the country.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) and panoramic x-ray (D0330) provided on May 3, 2021.  You asked the Plan to pay for the dental services. You say that you would like to appeal these services. The Plan denied your request. The Plan says the adjunctive pre-diagnostic test is not a covered service. The Plan also that your benefits for the panoramic x-ray have been satisfied and the frequency limitation has been exceeded. The Plan also says that you contacted the Plan prior to this date of service to verify benefits, and you were educated on the type of exams and x-rays that are covered along with their frequency limitations.  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, adjunctive pre-diagnostic test (D0431) is not among those covered under this benefit. The contract says that full mouth or panoramic x-rays is limited to one procedure code every five years. The record shows that the Plan paid for a full mouth x-ray that you received on the date of service in this case, thus reaching the frequency limit. Therefore, we decided that the Plan does not have to pay for the adjunctive pre-diagnostic test (D0431) and panoramic x-ray (D0330) provided on May 3, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for a massage therapy visit (97124) rendered on August 23, 2021.  You asked the Plan to pay for massage therapy. You say that although you had already had 10 massage therapy visits, the services continued to be medically necessary. The Plan denied your request. The Plan says this benefit had been exhausted at the time the services were rendered.  The Plan must follow Medicare rules. Medicare does not cover the services of a massage therapist. The Plan contract offers a supplemental benefit for massage therapy. The Plan covers 10 massage therapy visits during the calendar year.  We looked at the file and Medicare rules. The file indicates that by the time of the massage therapy visit on August 23, 2021, 10 visits had already been rendered. This indicates that the benefit had been exhausted. Therefore, we decided that the Plan does not have to pay for a massage therapy visit (97124) rendered on August 23, 2021.
Appeal type: SNF
Decision: Favorable

 We decided that the Plan has to pre-approve skilled nursing facility (SNF) care.  You asked the Plan to pre-approve SNF care. You say that the enrollee's health and wellbeing will decline if discharged from the SNF. The Plan denied your request. The Plan says that the guidelines for SNF care have not been met. The Plan says that continued SNF care 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 pre-approve SNF care. Our reviewer says that the criteria for coverage have been met. Our physician reviewer found the enrollee does qualify for ongoing SNF coverage.  The enrollee does have documented skilled nursing needs, as he receives 100% of his nutrition via enteral feeding.  The enrollee does not have documented skilled therapy needs.  Daily skilled services are required to establish a maintenance program or to prevent deterioration of the enrollee's condition.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF care have been met. The Plan must continue coverage for the SNF skilled service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing facility (SNF) care.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

 We decided that the Plan has to pay for the acute inpatient hospital care provided from June 4, 2021, to June 6, 2021.  You asked the Plan to pay for acute inpatient hospital care. You say that this inpatient stay was medically necessary. The Plan denied your request. The Plan says that the care needed could have been handled at a lower level of care.  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 supports that the criteria for inpatient payment are met in this case. Our physician reviewer found the record showed that at the time of inpatient admission the admitting physician reasonably expected that the patient'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 been met. Therefore, we decided that the Plan has to pay for the acute inpatient hospital care provided from June 4, 2021, to June 6, 2021.   If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve Botox.  You asked the Plan to pre-approve Botox. You say that this is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says this is not covered under the Plan's medical benefit.  The Plan must follow Medicare rules. Medicare rules say that, in order to be eligible for coverage under Part B, drugs/biologicals must represent an expense to the rendering physician and be included in the physician's bill.  In this case, the Plan reached out to request more information regarding whether the medication will be dispensed by a pharmacy and will be brought to the office for administration. No information was provided to the Plan regarding the administration of this drug. Without a response to who will be supplying the drug, we cannot review to see if the services should be covered under the medical benefit. Since it appears that the medication will not represent an expense to the physician and will not be included in the physician's bill, it will not be eligible for Part B coverage. Therefore, we decided that the Plan does not have to pre-approve Botox.
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 services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.  The Plan must follow Medicare rules. The rules say that 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 there are no services available at the LTACH that the enrollee requires that are not available at the health care setting being offered by the health plan. the requested LTACH services are not medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee and able to be furnished safely and effectively only on an inpatient basis.  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 X-ray of the chest (71045) provided on August 23, 2021.  You asked the Plan to pay for the X-ray of the chest. You say that you would like this claim reprocessed for medical necessity. The Plan denied your request. The Plan says this claim has not been billed with an appropriate modifier.  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 71045 is a column II code to column I code 71046. 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 of the chest (71045) provided on August 23, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve eight (8) additional physical therapy (PT) visits (97110).  You asked the Plan to pre-approve additional PT visits. You say that the requested additional PT visits are medically necessary. The Plan denied your request. The Plan says the requested additional PT visits do not meet criteria.  The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient therapy.   We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve additional PT visits. Our reviewer says that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's condition. Our physician reviewer found the enrollee appears to have improved with therapy (improved ambulation, balance and strength) and further treatment with the recently approved 12 additional therapy sessions should provide more improvement. Records do not document that the 12 recently approved sessions (in addition to the therapy she has already received) would be inadequate to treat her condition. Utilization of the home exercise program appears appropriate after completion of the additional approved sessions.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional PT visits have not been met. Therefore, we decided that the Plan does not have to pre-approve eight (8) additional physical therapy (PT) visits (97110).
Appeal type: DME/ Orthotics
Decision: Favorable

We decided that the Plan has to pre-approve advanced foot feature (CPT code L5981).

You asked the Plan to pre-approve the advanced foot feature. You say that the advanced foot feature is necessary. The Plan denied your request. The Plan says that the request for K3 foot does not meet Medicare criteria as 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 advanced foot feature. Our physician reviewer found based on your physician's notes/letter, you are very active and are truly at a K3 level. Therefore, this request for advanced foot feature on a prosthetic leg device is justified and 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 advanced foot feature have been met. Therefore, we decided that the Plan has to pre-approve advanced foot feature (CPT code L5981).

If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake and/or send us the new information. This does not happen often. If we decide to open the case again, we will send you a letter.
Appeal type: Inpatient Hospital
Decision: Favorable

We decided that the Plan has to pay for inpatient hospital care provided by an out-of-network provider on
March 14, 2021, through March 29, 2021.
You asked the Plan to pay for inpatient hospital care. You say that these services were medically necessary.
You say that you would like full reimbursement for the services provided. The Plan denied your request. The
Plan says that the member was medically stable.
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 case file is clear that the Plan received and reviewed medical
records for the dates of service at issue. The Plan has not forwarded the complete medical record to the IRE for
review. Without the complete medical record, the Plan denial is not substantiated, and we must find in your
favor. Therefore, we decided that the Plan has to pay for inpatient hospital care provided by an out-of-network
provider on March 14, 2021, through March 29, 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 transfer to an LTACH is necessary for the enrollee's condition to improve fully and avoid future hospital re-admissions. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The enrollee is receiving appropriate care in the hospital, and there is no advantage in transferring to an LTACH at this time.  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 in this case the enrollee requires ongoing acute care services. The enrollee is receiving acute care services at the current facility, and these have not been denied. The medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied; the requested service cannot be recommended.  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 anesthesia services (procedure code 01402) provided to the enrollee on May 7, 2021.  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 a surgical code that appropriately crosswalks to the anesthesia services must be reported to support the anesthesia code.  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 01402 is "Anesthesia for open or surgical arthroscopic procedures on knee joint; total knee arthroplasty."  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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the documentation submitted includes only an anesthesia report, documenting a "Robotic Arthroplasty Knee." If no operative report has been billed to support the anesthesia code reported, then the anesthesia code cannot be verified.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (procedure code 01402) provided to the enrollee on May 7, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for the train of four testing (95937) provided on June 23, 2021.  You asked the Plan to pay for the train of four testing. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says train of four monitoring is not separately payable.  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 95937 is neuromuscular junction testing (repetitive stimulation, paired stimuli), each nerve, any 1 method.  We find that CPT code 95937 is not supported in the record. Specifically train of four testing does not meet the CPT code Manual definition of CPT code 95937. Train of four monitoring is considered integral to the primary neuromonitoring procedure and is not separately payable. Based on this information, we decided that Medicare rules for coverage of the train of four testing have not been met. Therefore, we decided that the Plan does not have to pay for the train of four testing (95937) provided on June 23, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the rare disease panel (0241U) provided on July 1, 2021.  You asked the Plan to pay for the rare disease panel. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says this testing was not billed with the appropriate place of service code.  The Plan must follow Medicare rules. Medicare rules say that this service may only be billed in places of service 20, 21, 23, or 81.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the rare disease panel have not been met. Specifically, this claim was not billed with an appropriate place of service code. The record does not show that this testing was ordered by an infectious disease specialist. Therefore, we decided that the Plan does not have to pay for the rare disease panel (0241U) provided on July 1, 2021.
Appeal type: Testing
Decision: Unfavorable

 We decided that the Plan does not have to pay for digital analysis of electroencephalogram (EEG) provided to the enrollee from December 22, 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 digital analysis of an electroencephalogram (EEG) (code 95957) should only be reported when an EEG procedure was also performed for the enrollee.  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 95957 is "Digital analysis of electroencephalogram (EEG) (eg, for epileptic spike analysis)."  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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the technical report does not include documentation to support a digital analysis of EEG was performed. CPT 95957 should not be reported when the EEG was recorded digitally. The documentation does not support analysis of EEG, and cannot be verified.  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 services have not been met. Therefore, we decided that the Plan does not have to pay for digital analysis of electroencephalogram (EEG) provided to the enrollee from December 22, 2020.