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

We decided that the Plan does not have to pay for inpatient care provided to the enrollee from August 31, 2020, to September 22, 2020.
You asked the Plan to pay for these services. You say that this claim should be paid as billed. The Plan denied your request. The Plan says the primary and secondary diagnosis codes are reported incorrectly.
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. 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 these services. Our reviewer says that Medicare billing criteria are not met. Our physician reviewer found the medical records show the enrollee was admitted for chemotherapy-induced pancytopenia. The enrollee's treatment for Acute Myeloid Leukemia (AML) was held on August 2, 2020 due to persistent and worsening cytopenias. The enrollee was seen in the outpatient clinic on August 13, 2020 and treatment resumed, but with plan for 21-day course of venetoclax for count recovery. The records state the enrollee was last seen on August 28, 2020 and found again be to pancytopenic. As the counts remained low in the outpatient setting, the enrollee was admitted to the hospital. The plan was for a bone marrow biopsy to determine the etiology of the pancytopenia. The discharge summary states that the enrollee was admitted for recurrent pancytopenia after cycle 2 of outpatient chemotherapy. A bone marrow biopsy was done, and the physician stated in the discharge summary regarding the results, "0.05% blasts so pancytopenia was thought to be 2/2 chemotherapy with poorly recovering blood counts." In this case chemotherapy-induced pancytopenia met the definition of the principal diagnosis. Code D61.810 was sequenced as the principal diagnosis and code C92.00 was sequenced as secondary diagnosis on the claim. Based on the records provided and the Medicare guidelines, the claim should not be paid as submitted with the primary code of C92 as a principal diagnosis code. 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 care provided to the enrollee from August 31, 2020, to September 22, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a fibromyalgia test.
You asked the Plan to pre-approve the testing. You say that this test is not provided by any of the network providers. The Plan denied your request. The Plan says this test would not change treatment in this case.
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 testing. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.
Our physician reviewer found the requested test is a part of a research study with an out of network provider and does not change treatment in your case. The requested testing will not affect your medical management. 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 testing have not been met. Therefore, we decided that the Plan does not have to pre-approve a fibromyalgia test.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for critical care, first hour (99291) provided July 7, 2021.
You asked the Plan to pay for the critical care. You say that please consider full payment for the services provided and supported. The services were necessary for treatment of the enrollee. The Plan denied your request. The Plan says there is insufficient documentation to corroborate the service so that the Medicare coverage criteria has been met.
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 99291 is evaluation and management of the critically ill or critically injured patient, first 30-74 minutes.
We find that CPT code 99291 is not supported in the medical record. Specifically, the provider has not submitted any clinical records to support the medical necessity of the services. The records show that the Plan made several attempts to obtain the needed records without success. Based on this information, we decided that Medicare rules for coverage of the critical care have not been met. Therefore, we decided that the Plan does not have to pay for critical care, first hour (99291) provided July 7, 2021.
Appeal type: Inpatient Hospital
Decision: Partially Favorable

We decided that the Plan has to pay for continuous intraoperative neurophysiology monitoring (G0453). We
decided that the Plan does not have to pay for the central motor evoked potential study (95939) and shortlatency
somatosensory evoked potential study (95938).
You asked the Plan to pay for the central motor evoked potential study (95939), short-latency somatosensory
evoked potential study (95938) and continuous intraoperative neurophysiology monitoring (G0453). You say
that you would like reconsideration based on the records submitted. The Plan says that the diagnosis code
billed on the claim is invalid.
We decided that the Plan has to pay for continuous intraoperative neurophysiology monitoring (G0453).
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly.
We looked at your request, the file and Medicare rules. Based on this information we determined that Medicare
criteria for coverage of the continuous intraoperative neurophysiology monitoring have been met. Specifically,
Local Coverage Article A56722 includes a list of diagnosis codes that support the medical necessity of CPT
code G0453 but does not explicitly state that diagnosis codes not listed are non-covered. The Plan has not
provided any evidence that the diagnosis code billed on the claim does not support CPT code G0453.
Therefore, we decided that the Plan has to pay for continuous intraoperative neurophysiology monitoring
(G0453).
We also decided that the Plan does not have to pay for the central motor evoked potential study (95939)
and short-latency somatosensory evoked potential study (95938).
The Plan follows Medicare rules. Medicare rules say that providers must report services correctly.
We looked at your request, the file and Medicare rules. Based on this information we determined that Medicare
coverage criteria for the central motor evoked potential study and short-latency somatosensory evoked potential
study have not been met. Specifically, Local Coverage Article A56773 includes a list of appropriate diagnosis
codes for CPT codes 95938 and 95939. The diagnosis code billed is not included on the list of appropriate
codes. The Local Coverage Article states that any codes not listed, do not support the medical necessity of
codes 95938 and 95939. Therefore, we decided that the Plan does not have to pay for the central motor evoked
potential study (95939) and short-latency somatosensory evoked potential study (95938).
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake
and/or send us the new information. This does not happen often. If we decide to open the case again, we will
send you a letter.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for individual psychotherapy services (90837) provided April 1, 2021 to April 29, 2021.
You asked the Plan to pay for the psychotherapy services. You say that the counselor has been providing services to you since 3/28/2019. Both you and your counselor agree that continuing individual therapy is the best care for you, as it is beneficial for your emotional and mental stability. The Plan denied your request. The Plan says the services were received from an ineligible provider. the provider is not eligible to bill Medicare because the provider is a licensed professional counselor (LPC) and a LPC is not eligible to bill Medicare for mental health services.
The Plan must follow Medicare rules. The rules say that Medicare payment cannot be made to a provider that is not enrolled in the Medicare program. The Health Plan contract says that you can get your care from an out-of-network provider, however, in most cases that provider must be eligible to participate in Medicare. Except for emergency care, we cannot pay a provider who is not eligible to participate in Medicare. If you receive care from a provider who is not eligible to participate in Medicare, you will be responsible for the full cost of the services you receive. You can find this information on page 3-3 of the Plan's 2021 Evidence of Coverage. Review of the file and Medicare records indicates that the provider at issue is not enrolled in the Medicare program. Therefore, we decided that the Plan does not have to pay for individual psychotherapy services (90837) provided April 1, 2021 to April 29, 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 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 you do 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 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the pain management services rendered on March 5, 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 are not covered.
The Plan must follow Medicare rules. Medicare rules say that claims submitted where the unit of service exceeds the MUE value cannot be paid when the MAI value is 2. In this case, the MUE for CPT codes 64494 and 64495 is 1. The MAI value for these codes is 2. You billed 2 units of each code, exceeding the MUE. 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 pain management services rendered on March 5, 2021
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study coded 95938, the central motor evoked potential study coded 95939, the needle electromyography coded 95870, and the continuous intraoperative neurophysiology monitoring coded G0453 provided on January 11, 2021.
You asked the Plan to pay for the short-latency somatosensory evoked potential study, the central motor evoked potential study, the needle electromyography, and the continuous intraoperative neurophysiology monitoring. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services billed are not supported by the documentation.
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 95938, 95939, 95870, and G0453 are not supported in the medical record. Specifically, the medical records submitted indicate this procedure was performed in an on-campus outpatient Hospital (place of service code 22). However, the claim form indicates a different place of service, specifically an Inpatient Hospital (place of service code 21). The Place of Service billed must match the place of service where the face-to-face procedure took place; therefore, the billed services cannot be verified. Based on this information, we decided that Medicare rules for coverage of the short-latency somatosensory evoked potential study, the central motor evoked potential study, the needle electromyography, and the continuous intraoperative neurophysiology monitoring have not been met. Therefore, we decided that the Plan does not have to pay for the short-latency somatosensory evoked potential study coded 95938, the central motor evoked potential study coded 95939, the needle electromyography coded 95870, and the continuous intraoperative neurophysiology monitoring coded G0453 provided on January 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the computed tomography (CT) scan provided on August 30, 2019.
You asked the Plan to pay for the CT scan. You say that the enrollee had multiple exams on this date of service. The Plan denied your request. The Plan says it does not appear there were separate services.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate code. We find that CPT code 70450 was billed with code 70496. CPT code 70450 may be eligible for payment when billed with this code pair. The records do not show that the service at issue was billed with a modifier suitable for payment. Based on this information, we decided that Medicare rules for coverage of the CT scan have not been met. Therefore, we decided that the Plan does not have to pay for the computed tomography (CT) scan provided on August 30, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the hospital observation and injection services rendered on January 1, 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 are not separately payable.
The Plan must follow Medicare rules. The rules say that services with status indicator N are paid under the OPPS, but their payment is packaged into payment for a separately paid service. We looked at the file and Medicare rules. Billed procedure codes J1650 (enoxaparin sodium injection, 10mg), J2405 (ondansetron hcl injection, per 1mg), and G0378 (hospital observation services) have an OPPS status indicator of N and no separate payment. 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 observation and injection services rendered on January 1, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the services (70450) provided on September 2, 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 September 2, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on December 21, 2020, by an outof-
network (OON) provider.
You asked the Plan to pay for an office visit the office visit. You say that the service was medically necessary.
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
records provided for review do not show that the service at issue was urgent or emergent.
Therefore, we decided that the Plan does not have to pay for the office visit provided on December 21, 2020,
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 22, 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 22, 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 enrollee's renal; cardiac and neuro status is stable. The enrollee does not have any complex medical or nursing needs. The enrollees wound care needs can be met at a skilled nursing facility. 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: ER
Decision: Unfavorable

We decided that the Plan does not have to pay for the emergency room (ER) services rendered on June 17,
2019.
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 was not filed timely.
The Plan follows Medicare rules. The rules say that claims for services furnished on or after January 1, 2010,
must be filed no later than one calendar year after the date of service.
The record shows that a claim for these services was not filed until September 15, 2021. This means that more
than one calendar year from the date of service had passed before a claim was filed. Therefore, we decided that
the Plan does not have to pay for the emergency room (ER) services rendered on June 17, 2019.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the acupuncture visits coded as 97810, 97811, 99211, 99203, 99212 provided February 23, 2021 to April 22, 2021.
You asked the Plan to pay for the acupuncture services. You say that you do not understand why the Plan has not paid this provider. She refused to see you unless you agree to pay cash because the has not been paid by the Plan. The Plan denied your request. The Plan says acupuncture and therapy services provided by a licensed acupuncturist for the diagnosis of throat pain is not covered by Medicare or the Plan.
The Plan must follow Medicare rules. The rules say that acupuncture services are not covered by Medicare. However, for services provided on or after January 21, 2020, Medicare offers limited coverage for acupuncture treatments for CLBP meeting certain requirements, up to 12 sessions per 90-day period, and no more than 20 sessions per year. However, your Plan offers coverage beyond the Medicare acupuncture benefit. As such, the Plan's rules apply in this case. We looked at the file and Medicare rules. Based on this information, we decided that the rules for coverage of the acupuncture services have not been met. Specifically, acupuncture is only covered for the treatment of chronic low back pain. Acupuncture for the treatment of throat pain is not covered. Therefore, we decided that the Plan does not have to pay for the acupuncture visits coded as 97810, 97811, 99211, 99203, 99212 provided February 23, 2021 to April 22, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the office visit provided on April 24, 2021, by an out-of-network (OON) provider.
You asked the Plan to pay for the office visit. You say that this claim is reimbursable, just like in-network claims. 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. Therefore, we decided that the Plan does not have to pay for the office visit provided on April 24, 2021, by an out-of-network (OON) provider