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

We decided that the Plan does not have to pay for the pathology services provided on February 8, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the pathology services. You say that the enrollee was seen by an in-network facility, but there was not an in-network laboratory to be used to offer the appropriate medical treatment. 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 record shows the referring provider was out-of-network. Therefore, we decided that the Plan does not have to pay for the pathology services provided on February 8, 2021, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on July 16, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is a bundled
service.
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 70450
is a column II code to column I code 70496. 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 services (70450) provided on July 16, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

We decided that the Plan does not have to pay for the therapeutic procedures (97110) provided on October 16, 2019.
You asked the Plan to pay for the therapeutic procedures. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says there is a more appropriate code for the billed service.
The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must corroborate the documentation in the beneficiary's medical documentation and confirm that Medicare coverage criteria have
been met. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the therapeutic procedures have not been met. Specifically, the documentation submitted does not include any medical records. There is insufficient information to determine if Medicare criteria for coverage of the therapeutic procedures have been met. Therefore, we decided that the Plan does not have to pay for the therapeutic procedures (97110) provided on October 16, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital discharge day management services rendered on August 5, 2020.
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 claim is a duplicate.
The Plan must follow Medicare rules. The rules say that claims or claim lines that have been determined to be exact duplicates of another claim or claim line are denied. We looked at the file and Medicare rules. The file shows that the services at issue were previously paid by the Plan on a separate claim for the same date of service. 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 hospital discharge day management services rendered on August 5, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia supplies (A4550, A4556, A4557, A4624, A7001, A7002, A4649, S1015, S8301) provided February 24, 2021.
You asked the Plan to pay for the anesthesia supplies. You say that the items were medically necessary. The Plan denied your request. The Plan says the claim cannot be paid 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 CPT codes A4550, A4556, A4557, A4624, A7001, A7002, A4649, S1015, and S8301 are not supported. Specifically, CPT codes A4624, A7001, A7002, E0431, E0424 and E0600 have a status of "X" per the National Physician Fee Schedule and are not separately payable. CPT codes A4550, A4556, and A4557 have a status of "B" and payment is always bundled in payment for another service. CPT codes S1015, & S8301 have a status of "I" and are ineligible for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the anesthesia supplies have not been met.
Therefore, we decided that the Plan does not have to pay for anesthesia supplies (A4550, A4556, A4557,
A4624, A7001, A7002, A4649, S1015, S8301) provided February 24, 2021.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve home infusion services (A4223, S9379, 99602, 99601).
You asked the Plan to pre-approve the home infusion services. You say that the services are medically necessary. The Plan denied your request. The Plan says the requested CPT codes are not eligible for Medicare payment.
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 CPT codes A4223, S9379, 99602, & 99601 are not supported. Specifically, per the National Physician Fee Schedule these codes have a status of "I" and "X" and are invalid for Medicare payment. Based on this information, we decided that Medicare rules for coverage of the home infusion services have not been met. Therefore, we decided that the Plan does not have to pre-approve home infusion services (A4223, S9379, 99602, 99601).
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), spinal canal and contents (72148).
You asked the Plan to pre-approve the MRI. You say that the medical records provided will show proof of medical necessity. The Plan denied your request. The Plan says the medical necessity criteria has not been met as there was no documentation that any conservative treatments had been tried and failed.
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 the MRI. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found in this case, the record indicates that the enrollee has low back pain. The record indicates that the pain is improved with medication. The record does not indicate acute neurologic deficit or failed conservative treatment. The record does not indicate the occurrence of acute injury. The requested service is not medically necessary and reasonable for the diagnosis and treatment for the enrollee's clinical condition at this 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 the MRI have not been met. Therefore, we decided that the Plan does not have to pre-approve magnetic resonance imaging (MRI), spinal canal and contents (72148).
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 enrollee requires IRF care, and this is the only
facility within 60 miles that will adequately meet the enrollee's needs. The Plan denied your request. The Plan
says the criteria for admission to an IRF are not met. The enrollee can safely receive the services they need in
an alternate setting.
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 that 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. 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. There is not a reasonable expectation that this enrollee
will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an
IRF.
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: 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 enrollee requires ongoing care and would benefit from transfer to an LTACH. The Plan denied your request. The Plan says the criteria for admission to an LTACH are not met. The provided records show that the enrollee no longer has an illness that is complex enough to require further hospital care including seeing a doctor every day. The enrollee does need continued care including PEG tube feeding and medication management, some therapy and routine skilled nursing services. The necessary care can be provided in an alternate setting, such as a skilled nursing facility.
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's medical condition is not complex enough to require services in an LTACH. The necessary care, including PEG needs and medication management, can be provided in a skilled nursing facility. The requested LTACH services are not medically necessary and will not change the short or long-term outcome for the enrollee.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of 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: Inpatient Hospital
Decision: Unfavorable

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 does not meet
criteria.
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 enrollee does not require treatment by multiple therapies, including either
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. There is not a
reasonable expectation that the enrollee will be able to fully participate in and benefit from the intensive
rehabilitation therapy program provided in an IRF.
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: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 10, 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 were not billed correctly.
The Plan must follow Medicare rules. Medicare rules say that claims must be billed with the correct place of service (POS) code. We looked at the file and Medicare rules. The claim for these services was billed with POS code 81 for a laboratory setting; however, the file shows that the specimen was obtained in an outpatient hospital setting and should have been billed with POS code 22. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 10, 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 enrollees renal; cardiac and neuro function are clinically stable. The enrollee does not have an acute vent need, complex medical or nursing need or a complex wound care need. There is no medical need for a LTACH. 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) service
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from December 6, 2021 forward.
You asked the Plan to pre-approve a continued inpatient psychiatric admission. You say that a continued inpatient psychiatric admission is medically necessary. The Plan denied your request. The Plan says your psychiatric record shows that on December 6, 2021, your medical regimen was stable and you no longer required an inpatient level of psychiatric care.
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 a continued inpatient psychiatric
admission. Our reviewer says that a continued inpatient psychiatric admission is not medically necessary. Our
physician reviewer found that you did not appear to require inpatient mental health treatment beyond the date
in question as you were not a danger to yourself or others, no auditory hallucinations or visual hallucinations
while being cooperative with treatment. It did not appear that active treatment was taking place beyond the date
in question. It did not appear that the services were reasonably expected to improve your condition or for the
purpose of diagnosis beyond the date in question. It did appear that the records were supervised and evaluated
by a physician. Based upon review the records provided for the admission, you do not meet the criteria for
continued acute inpatient mental health treatment from December 6, 2021, forward as you were not shown to
be a danger to yourself or others. You were not showing any auditory or visual hallucinations and were
cooperative/compliant with treatment. You were not showing any aggressive behaviors or any treatment
required for acute threats of safety.
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 continued inpatient psychiatric admission have not been met. Therefore, we
decided that the Plan does not have to pre-approve a continued inpatient psychiatric admission from December
6, 2021 forward
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve prednisone tablets.
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says self-administered drugs are not covered.
The Plan must follow Medicare rules. The rules say that Medicare Part B generally does not pay for self-administered drugs. The self-administered drugs requested here are not among the types which are covered by Medicare Part B. Therefore, we decided that the Plan does not have to pre-approve prednisone tablets.
Benefits for these services may be available under Medicare Part D. Contact the Plan that administers Part D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for laboratory services (procedure code 0242U) provided to the enrollee on May 11, 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 Current Procedural Terminology (CPT) code 0242U (1 Unit) remains 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 0242U is "Targeted genomic sequence analysis panel, solid organ neoplasm, cell-free circulating DNA analysis of 55-74 genes, interrogation for sequence variants, gene copy number amplifications, and gene rearrangements." We find that CPT code 0242U is 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 doctor's office (POS 11). 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 (procedure code 0242U) provided to the enrollee on May 11, 2021.
Appeal type: Outpatient Mental Health
Decision: Unfavorable

We decided that the Plan does not have to pay for psychotherapy services (90847) provided on January 6 to May 26, 2021.
You asked the Plan to pay for psychotherapy services. You say that you were not aware that your provider has opted out of Medicare. The Plan denied your request. The Plan says rules for payment have not been met because the provider of the services at issue has opted out of Medicare.
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 the provider who has opted out of the Medicare program. Therefore, we decided that the Plan does not have to pay for psychotherapy services (90847) provided on January 6 to May 26, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99243) provided on April 14, 2021.
You asked the Plan to pay for the services. The Plan denied your request. The Plan says this is not a covered service.
The Plan must follow Medicare rules. Medicare rules say that a status indicator of "I" under the Physician Fee Schedule indicates that the code in question is not valid for Medicare purposes. We looked at the file and Medicare rules. Code 99243 is assigned a status indicator of "I" under the Physician Fee Schedule, which means that this code is not valid for Medicare purposes. Medicare uses another code for reporting of, and payment for, these services. 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 the services (99243) provided on April 14, 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 IRF services are medically necessary. The Plan denied your request. The Plan says the criteria for admission to an IRF are not met. The enrollee's ongoing skilled therapy and nursing needs can be provided at a lower level of care.
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 that 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. 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. There is not a reasonable expectation that this enrollee will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 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