Persius/hicric huggingface dataset:
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided May 11, 2021 to 
May 16, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you would like the plan to reconsider 
their denial. The Plan denied your request. The Plan says the services provided were not medically necessary. 
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 enrollee presented to the emergency department from the nursing facility with 
stabbing chest pain. Workup revealed Brain natriuretic peptide (BNP) was 355, D-Dimer 0.71. 
Electrocardiogram heart rate was 137 with atrial fibrillation with rapid ventricular rate (new). The enrollee was 
started on Cardizem drip and monitored. The enrollee was admitted for further workup and digoxin, morphine, 
fluids. The enrollee is chronically on Eliquis for chronic atrial fibrillation. Acute coronary syndrome was ruled 
out. Gastrointestinal workup was continued. The enrollee's vitals were stable. Based on the provided 
documentation, the cardiac workup only showed chronic disease and no acute findings to justify inpatient 
treatment. Gastrointestinal workup could have been completed at a lower level of care. The notes suggest the 
enrollee did not require hospital services that were likely to cross 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 May 11, 2021 to May 16, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a third-level facet joint injection.

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 the services are not covered.

The Plan must follow Medicare rules. The rules say that one to two levels, either unilateral or bilateral, are allowed per session per spine region. 

We looked at the file and Medicare rules. The requested services are a facet injection at a third level. 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 pre-approve a third-level facet joint injection.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the moderate sedation services provided during a spinal procedure on December 10, 2020, billed with codes 99152 and 99153.

You asked the Plan to pay for the moderate sedation services. You say that this was correctly coded and should be paid. The Plan denied your request. The Plan says there was not sufficient documentation of a train observer to support codes 99152 and 99153.

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 99152 is Moderate sedation services provided by the same physician or other qualified health care professional performing the diagnostic or therapeutic service that the sedation supports, requiring the presence of an independent trained observer to assist in the monitoring of the patient's level of consciousness and physiological status; initial 15 minutes of intraservice time, patient age 5 years or older. 99153 is for each additional 15 minute interval of this service. 

We find that CPT code 99152 is not supported in the medical record. Specifically, the operative note does not document the presence of a independent trained observer as required by the code. Because 99152 is not supported, the add-on code 99153 is not supported. Based on this information, we decided that Medicare rules for coverage of the moderate sedation services have not been met. Therefore, we decided that the Plan does not have to pay for the moderate sedation services provided during a spinal procedure on December 10, 2020, billed with codes 99152 and 99153.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided May 6, 2021 - 
May 6, 2021. 
 
You asked the Plan to pay for acute inpatient hospital care. You say that you disagree with the denial. The Plan 
denied your request. The Plan says the services were not medically necessary. 
 
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 enrollee was brought to the emergency room (ER) with complaints of rectal 
bleeding and black stools. He was evaluated and admitted for a lower gastrointestinal (GI) bleed. There was no 
blood on rectal exam and he had brown stool and minimal abdominal tendencies. The records do not show that, 
at the time of inpatient admission, the admitting physician reasonably expected that the enrollee's necessary 
hospital care (including earlier ED 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 May 6, 2021 - May 6, 2021.
Appeal type: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on
April 7, 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 submitted records do not support the billing of code 99285.
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 99285 is Level 5 emergency department visit for evaluation and management of patient with problem immediately threatening physiologic function, including comprehensive history and physical examination, and medical decision-making of high complexity.
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 these services. Our reviewer says that the submitted records do not support the billing of code 99285. Our reviewer found the documentation does not meet the criteria for code 99285. The submitted history supports an expanded problem focused history, a comprehensive exam, and medical decision making supports only moderate complexity. We looked at this coder's review, the file, and Medicare rules. 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 emergency room (ER) services rendered on April 7, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a below the knee flexible protective outer surface covering system and a lower extremity prostheses flex foot system.
You asked the Plan to pre-approve a below the knee flexible protective outer surface covering system and a lower extremity prostheses flex foot system.
You say that the items which remain in dispute are medically necessary. The Plan denied your request. The Plan says there is no documentation that supports the enrollee's activity subjects her to harsh environmental situations or that she engages in any extraordinary activities that would justify the need for extra protection. The Plan says that the code being requested for the lower extremity prostheses flex foot system does not properly represent the item that is being ordered by the doctor.
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 a below the knee flexible protective outer surface covering system and a lower extremity prostheses flex foot system. Our reviewer says that the requested items are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee does not have special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower limb prosthesis beyond the level of protection that is afforded by L5704. The L5980 All Lower Extremity Prostheses, Flex Foot System exceeds the enrollee's medical need as it is not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. The L5980 is not medically necessary to build the requested foot 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 a below the knee flexible protective outer surface covering system and a lower extremity prostheses flex foot system have not been met. Therefore, we decided that the Plan does not have to pre-approve a below the knee flexible protective outer surface covering system and a lower extremity prostheses flex foot system.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office visit and laboratory services to be rendered by 
the out-of-network (OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you are requesting a reconsideration of the 
Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render 
the requested services. 
 
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 services at issue in this appeal.  

We found no exception that would require the Plan to pre-approve these services. Therefore, we decided that 
the Plan does not have to pre-approve an office visit and laboratory services to be rendered by the out-of-
network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve an office consultation to be rendered by the out-of-network provider.

You asked the Plan to pre-approve this service. You say that you are requesting a reconsideration of the Plan's denial. The Plan denied your request. The Plan says there are in-network providers available to render the requested service.

The Plan must follow Medicare rules. The rules say that except for emergency and urgently needed services, plans are not required to make payments for any services received by enrollees that are not provided directly by the Plan or through arrangements made by the Plan. 

The service at issue in this appeal will not be provided in an emergency or urgent care situation. The Plan is not providing this service and is not making arrangements to provide this service. Therefore, we decided that the Plan does not have to pre-approve an office consultation to be rendered by the out-of-network provider.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. 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 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 daily 
skilled services are not necessary. Our physician reviewer found the beneficiary does not require skilled 
nursing or therapy services on a daily basis. This beneficiary does not meet severity of illness or intensity of 
service criteria for an inpatient basis in a skilled nursing facility 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 SNF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve skilled nursing facility (SNF) care.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for a limited oral evaluation (D0140), a periapical first radiographic image (D0220), a periapical additional radiographic image (D0230), a cone beam computed tomography (CT) (D0364) and endodontic therapy (D3330) provided on July 9, 2021, by an out-of-network (OON) provider.

You asked the Plan to pay for a limited oral evaluation, a periapical first radiographic image, a periapical additional radiographic image, a cone beam (CT) and endodontic therapy. You say that when you called the provider's office, you were told that they were unsure if the office accepted your insurance or not. The Plan denied your request. The Plan says the provider is not a plan participating provider. The Plan also says that you did not contact the Plan prior to the date of service to verify the provider's network status nor did you call to obtain a list of in-network providers that you could have possibly went to for the services.

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. The Plan covers a limited oral evaluation, a periapical first radiographic image, a periapical additional radiographic image, a cone beam (CT) and endodontic therapy when the services are rendered with an in-network provider.

We looked at the file and Medicare rules. The EOC confirms that you are responsible for 100% of the cost for dental services rendered by an OON provider. Based on this information, we decided that the Plan's rules for coverage of a limited oral evaluation, a periapical first radiographic image, a periapical additional radiographic image, a cone beam (CT) and endodontic therapy have not been met. Therefore, we decided that the Plan does not have to pay for a limited oral evaluation (D0140), a periapical first radiographic image (D0220), a periapical additional radiographic image (D0230), a cone beam computed tomography (CT) (D0364) and endodontic therapy (D3330) provided on July 9, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a 3-in-1 heavy duty commode chair.
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 the services are not covered.
The Plan must follow Medicare rules. The rules say that a commode chair is covered only for enrollees who are confined to a bed or room. The rules say that an extra wide/heavy duty commode chair (E0168) is covered for a beneficiary who weighs 300 pounds or more. The file does not show that you are confined to a bed or room as defined by Medicare rules. The file also shows that you do not weight 300 pounds or more. Therefore, we decided that the Plan does not have to pre-approve a 3-in-1 heavy duty commode chair.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the radiofrequency ablation (RFA) of the lateral branches of the sacroiliac (SI) joint nerves provided on March 22, 2021.
You asked the Plan to pay for the SI joint RFA procedure. You say that it is felt that this was a medically necessary procedure that should be covered by Medicare. The Plan denied your request. The Plan says this is not a proven procedure.
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 pay for the SI joint RFA procedure. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the enrollee's sacroiliitis is proven by physical exam and due to positive response to SI joint injection on August 27, 2020. However, RFA of the SI joint nerves is considered experimental/investigational due to the wide variation in efficacy reported in the literature. Therefore, the procedure is considered not medically reasonable or 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 SI joint RFA procedure have not been met. Therefore, we decided that the Plan does not have to pay for the radiofrequency ablation (RFA) of the lateral branches of the sacroiliac (SI) joint nerves provided on March 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve dialysis services to be provided by an out-of-network 
(OON) provider. 
 
You asked the Plan to pre-approve these services. You say that you have been using this dialysis center for six 
years. The Plan denied your request. The Plan says the services are available from network providers. 
 
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 dialysis services to be provided by an out-of-network (OON) 
provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pay for the vitamin injections (J3490 x 3) provided on May 24, 2021.

You asked the Plan to pay for the vitamin injections. You say that the services should be covered. The Plan denied your request. The Plan says vitamin injections into the nerve and musculoskeletal structures are not a Medicare covered service.

The Plan must follow Medicare rules. Medicare rules say that claims for compounded drugs shall be submitted using a compounded drug, not otherwise classified (NOC) code. 

We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the vitamin injections have not been met. The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The rules require that any compounded drug be billed using the not otherwise classified code J7999. As this compounded drug was not billed properly, payment cannot be made.

Because the drugs are not paid as billed, the drug administration code, 96372, also cannot be paid. Therefore, we decided that the Plan does not have to pay for the vitamin injections (J3490 x 3) provided on May 24, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical therapy services (99212, 97112, 97032, 97016) 
and drugs (96372, J3490, J3415, J3411, J3420) provided on March 11, 2021. 
 
You asked the Plan to pay for the services. You say that these services were medically necessary for the 
enrollee's condition. The Plan denied your request. The Plan says the procedure as rendered is considered 
experimental/investigational. 
 
Therapy services (99212, 97112, 97032, 97016) 
 
The Plan must follow Medicare rules. Medicare rules say that payment is only made for physical therapy 
services rendered by an NP/PA only when they are licensed under State law.  
 
Review of the file and publicly available records, we find that the physical therapy services at issue in this case 
were rendered by an NP/PA who is not licensed to provide physical therapy in the State of Arizona. Based on 
this information, we decided that Medicare rules for coverage of the physical therapy services have not been 
met.  
 
Drug services (96372, J3490, J3415, J3411, J3420) 
 
The Plan must follow Medicare rules. Medicare rules say that compounded drugs shall be submitted using a 
compounded drug NOC code. 
 
The multiple drug codes reported on this claim refer to a pre-filled compounded drug/vitamin syringe. The 
rules require that any compounded drug be billed using the not otherwise classified code J7999. As this 
compounded drug was not billed properly, payment cannot be made. Because the drugs are not paid as billed, 
the drug administration code, 96372, also cannot be paid. 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 medical therapy services (99212, 97112, 97032, 97016) and drugs (96372, J3490, J3415, J3411, J3420) 
provided on March 11, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a shower chair.
You asked the Plan to pre-approve a shower chair. You say that the enrollee suffers from quadriplegia and is wheelchair and bed bound. The enrollee requires extensive day to day care with all of his activities of daily living. You say that the enrollee requires a shower chair in order to bathe daily. You say that this is medical equipment he cannot go without and is necessary for his safety, well-being, and to keep him in good health. The Plan denied your request. The Plan says bathtub seats are considered hygienic equipment and are not medical in nature.
The Plan must follow Medicare rules. Medicare rules say that shower chairs are not covered because they are not primarily medical in nature. While a shower chair may be appropriate in this case, neither the Plan nor Medicare offers coverage of this item. Therefore, we decided that the Plan does not have to pre-approve a shower chair.