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

We decided that the Plan does not have to pay for surgical services (procedure codes 31267, 31299) provided to the enrollee on June 1, 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 the records do not support the services 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. In this case, the CPT Code Manual definition of the denied codes is: CPT 31267: Nasal/sinus endoscopy, surgical, with maxillary antrostomy; with removal of tissue from maxillary sinus CPT 31299: Unlisted procedure, accessory sinuses.
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 based on the available clinical documentation, it appears that neither of the two denied codes were rendered in this case. First, the American Academy of Otolaryngology-Head and Neck Surgery CPT for ENT guidance on sinusectomy last updated 4/2/21 states that if only purulent material and not tissue is removed from a given sinus, the CPT code 31231 (nasal/sinus endoscopy, diagnostic, unilateral or bilateral (separate procedure)) would be appropriate. The operative report dated 6/1/21 stated that "mucopurulent debris" was removed from the left maxillary and ethmoid sinuses, and that the maxillary sinus ostium was already widely patent. Therefore, the record does not support that CPT 31267 was rendered. Second, it is possible that the "unlisted procedure" of the accessory sinuses (CPT 31299) refers to the procedure reported as "left anterior ethmoid artery ligation, endoscopic." The enrollee had a history of multiple episodes of bilateral epistaxis, including "bleeding on the left side that is high volume." Under endoscopic visualization, the left anterior ethmoid artery was ligated using bipolar electrocautery, resulting in "substantial reduction in bloody ooze from this region." The Accreditation Council for Graduate Medical Education (ACGME) otolaryngology case log coding guidelines indicate that CPT code 30915 may be used for ethmoid artery ligation. The ACGME otolaryngology coding guidelines also state that CPT code 31238 may be used for endoscopic control of epistaxis, which was described in the operative report as stated above. Therefore, the record does not support that CPT 31299 was rendered. 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 surgical services (procedure codes 31267, 31299) provided to the enrollee on June 1, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided on October
13, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for a domiciliary or rest home visit. You say that the referring provider requested
this provider be called in to see the patient as an attending provider in an outpatient capacity. You also say that
there is a medical necessity pre-established with the patient and the facility for this provider to provide services
to the patients needing care. The Plan denied your request. The Plan says this provider is not a network
provider with the Plan. The Plan also says that they have also determined that these services are not urgent or
emergent, nor were they approved in advance.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the
Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies,
out of area urgent care and pre-approved care.
The requested provider in this case is not a network provider with the Plan. The Plan had network providers
available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the
item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for a domiciliary or rest home visit (99336) provided
on October 13, 2021, by an out-of-network (OON) provider.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Motegrity tablet 2mg for the enrollee.
You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says this self-administered drug does not fall under Part B coverage.
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 Motegrity tablet 2mg for the enrollee.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states the enrollee can safely receive the services they need in other settings, for example: a skilled nursing facility, home with home health services, or home with outpatient therapy.
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 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. The enrollee was admitted for a seizure. Medical problems are stable. There are no complex nursing or rehabilitation needs.
The enrollee does not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the enrollee has a need for physical and/or occupational therapy, there is no documentation of a need for an intensive 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 IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on October 19, 2021.

You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.

Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan must pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. 

The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.

Therefore, we decided that the Plan does not have to pay for out of network medical services provided to the enrollee on October 19, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the acupuncture services to be provided by an out-ofnetwork (OON) provider.
You asked the Plan to pre-approve the acupuncture services. You say that you suffer with over active bladder
and you learned that acupuncture is an effective and successful treatment for over active bladder. You want to
be treated with acupuncture and have seen him before. The Plan denied your request. The Plan says enrollee's
must receive their medical services from an in-network provider with the exception being urgent or emergent
services. Non-emergent services with non-contracted providers require prior authorization before services
being rendered. Acupuncture is only covered for the treatment of chronic lower back pain.
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
the acupuncture services to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the annual wellness visit rendered on October 14, 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 benefit limit is exhausted.

The Plan must follow Medicare rules. These rules say that enrollees are eligible for coverage of an AWV once every 12 months. 

Based on review of the file, an annual wellness visit (AWV) was provided less than 12 months prior to the visit at issue in this case. The file shows that you previously had an AWV on June 14, 2021 that the Plan covered. Therefore, we decided that the Plan does not have to pay for the annual wellness visit rendered on October 14, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.

You asked the Plan to pre-approve IRF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says the stay is not medically necessary based on IRF criteria. The Plan states you could receive care in another setting, and the Plan could review alternate settings if requested such as a skilled nursing facility, outpatient setting or home health 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 the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You were admitted for lower extremity ulcer and had a below the knee amputation. Medical problems are stable. There are no complex nursing or rehabilitation needs. You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you 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 IRF admission and services.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve the Artelon tendon graft for the enrollee.
You asked the Plan to pre-approve the graft. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a standard treatment for tendon repair.
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 graft. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found the record indicates that the enrollee has posterior tibial tendinopathy and a partial tear of the tendon. There is insufficient literature to establish the requested service as a standard of care for the enrollee's specific clinical condition. The record provided does not establish the medical necessity and reasonableness, as defined by Medicare rules, of the requested service. The elements of the coverage criteria are not satisfied.
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 graft have not been met. Therefore, we decided that the Plan does not have to pre-approve the Artelon tendon graft for the enrollee.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) genomic sequencing panel provided on July 27, 2021, billed with code 81455.
You asked the Plan to pay for the F1Heme panel as billed. You say that this is a medically necessary panel for evaluation of hematolymphoid diseases. The Plan denied your request. The Plan says this is not a covered test as it is not likely to impact therapeutic decision making.
The Plan must follow Medicare rules. Medicare rules say that there is sufficient evidence to support the medical necessity of Genomic Sequential Analyses panels for patients with AML, MPN, and MDS for a limited number of individual biomarkers. Panels which test the covered biomarkers and are described by code 81450 may be covered by Medicare. We looked at the file and Medicare rules. Review of the information in the file shows that this panel includes analysis of over 50 genes. The billed code 81455 is defined as targeted genomic sequencing with analysis for 51 or more genes. Although some of these genes may be considered medically necessary based on the rules, the entire panel exceeds what is covered under these provisions. Therefore, we decided that the Plan does not have to pay for the FoundationOne Heme (F1Heme) genomic sequencing panel provided on July 27, 2021, billed with code 81455.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services rendered on May 29, 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 services are not covered.

The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.

The tests at issue in this appeal were requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services rendered on May 29, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from August 19, 2021, to August 23, 2020.
You asked the Plan to pay for the services. You say that this was medically necessary. The Plan denied your request. The Plan says the DRG was updated in this case.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. In this case, you billed the inpatient services provided with DRG 871 (SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC). 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 services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our physician reviewer found the review indicates that the documentation supported an admission for pulmonary embolism. The medical record received and available for review did not support sepsis as a diagnosis for this admission. The review has determined that DRG 871: SEPTICEMIA OR SEVERE SEPSIS WITHOUT MV >96 HOURS WITH MCC was not supported in the medical records. The appropriate DRG was DRG 175: PULMONARY EMBOLISM WITH MCC OR ACUTE COR PULMONALE. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided to the enrollee from August 19, 2021, to August 23, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for out of network medical services provided to the enrollee on October 13, 2021.
You asked the Plan to pay for this service. You say that this claim should be paid. The Plan denied your request. The Plan says the enrollee did not have prior authorization for out of network care.
Medicare rules say that plans can require enrollees to get care from network providers. The contract with the Plan says that the Plan has to pay for care from out-of-network providers only in cases involving emergencies, out of area urgent care and pre-approved care. The provider in this case is not a network provider with the Plan. The Plan had network providers available who could have provided the items/services at issue in this appeal. The Plan did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services.
Therefore, we decided that the Plan does not have to pay for out of network medical services provided to the enrollee on October 13, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a continuation of inpatient psychiatric care from
February 23, 2022, forward.
You asked the Plan to pre-approve the continuation of inpatient psychiatric care. You say that the enrollee lived
at home along and cannot go back due to dementia. You say that the enrollee needs to continue inpatient
psychiatric care. The Plan denied your request. The Plan says the guidelines for coverage have not been met.
The Plan says that the enrollee could be treated in a lower level of 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 the continuation of inpatient psychiatric
care. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found the
enrollee was admitted to the acute inpatient psychiatric hospitalization on February 15, 2022, with Major
Neurocognitive Disorder, Most Likely Due to Vascular Illness with Behavioral Disturbance. Based upon
review the records provided it was not expected this enrollee would improve in a reasonable period of time for
the dates in question as she did not have suicidal or homicidal ideation noted and no auditory or visual
hallucinations. The enrollee did not show any abnormal behaviors or any symptoms which would require acute
treatment. It did not appear medically necessary and reasonable to have psychiatric care provided at the acute
inpatient level of care rather than a lower level of care beyond the dates in question as she did not have
dangerousness to self or others but was compliant with her treatment with encouragement. It did not appear that
the services were reasonably expected to improve the enrollee's condition or for the purpose of diagnosis
beyond the date in question.
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 continuation of inpatient psychiatric care have not been met. Therefore, we
decided that the Plan does not have to pre-approve a continuation of inpatient psychiatric care from February
23, 2022, forward.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (99291) provided on July 8, 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 99291
is a column II code to column I code 36556. 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 (99291) provided on July 8, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for inpatient hospital services provided from
August 27, 2021, to September 2, 2021.
You asked the Plan to waive the copayment for the inpatient hospital services. You say that you thought it was
covered with detox. 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 $200 per
day for days 1-5 and $0 per day after day 5 for each inpatient benefit period.
The file shows that you were in the hospital from August 27, 2021, to September 2, 2021. Therefore, you have
been asked to pay $200 per day for the first 5 days of inpatient hospital services. The total for your stay is
$1,000 ($200 copayment x 5 days = $1,000). The inpatient hospital services fall within the Inpatient Hospital
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 inpatient hospital services
provided from August 27, 2021, to September 2, 2021.