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

We decided that the Plan does not have to pre-approve inpatient psychiatric hospital services.
You asked the Plan to pre-approve inpatient psychiatric hospital services. You say that these services are
medically necessary. The Plan denied your request. The Plan says that you can continue treatment in the
outpatient setting.
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 inpatient psychiatric hospital services.
Our reviewer says that inpatient psychiatric hospital services are not medially reasonable and necessary. It is
not expected you would improve in a reasonable period of time as you do not have dangerousness to self or
others, auditory or visual hallucinations, delusions and were not showing any behavioral issues. It does 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 as you do not have dangerousness to self or others, perceptual disturbance
including delusions, auditory or visual hallucinations. Our physician reviewer found that your condition does
not meet Medicare criteria for inpatient psychiatric hospital services.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of inpatient psychiatric hospital services have not been met. Therefore, we decided
that the Plan does not have to pre-approve inpatient psychiatric hospital services.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services coded 81295 and 81298 provided on April 27, 2021.
You asked the Plan to pay for the laboratory services. 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 separately payable.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code. In this case, we have confirmed that codes 81295 and 81298 for the laboratory services have a bundled relationship with code 81432 and cannot be paid as billed. This code cannot be paid as a separate line item. 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 laboratory services coded 81295 and 81298 provided on April 27, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a portable ventilator.
You asked the Plan to pre-approve a portable ventilator. 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 follows Medicare rules. Medicare rules say that ventilators (E0465, E0466, and E0467) are covered for specific conditions. 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 portable ventilator. Our reviewer says that the services are not medically necessary. Our physician reviewer found based on the medical records provided there is no documentation that you meet the coverage criteria detailed in the Local Coverage Determination (LCD): Respiratory Assist Devices, L33800 for the requested non-invasive home ventilator (E0466). Records indicate you will be using the home mechanical ventilator (E0466) in a bilevel positive airway pressure (BiPAP) mode. 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 portable ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve a portable ventilator.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for the tongue biopsy provided on April 22, 2021 by an out-of-network (OON) provider.

You asked the Plan to pay for the OON biopsy services. You say that you were not aware that this provider was out of network. You were told that they accepted your insurance and were not aware this was only for accident-related dental care. The Plan denied your request. The Plan says this provider is out of network with your plan. There was no referral by a network provider nor authorization requested

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 the tongue biopsy provided on April 22, 2021 by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia services provided on March 12, 2021.
You asked the Plan to pay for anesthesia for patient of extreme age (99100). You say that the Plan should pay this claim. The Plan denied your request. The Plan says this service is always bundled into payment for other services and no separate payment is made.
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 99100 has a bundled relationship with code 00211 and cannot be paid as billed. Code 99100 has a status code of B, bundled service. This code cannot be paid as a separate line item. Based on the claim submitted, Medicare billing criteria have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia services (99100) provided on March 12, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that these services are medically necessary. The Plan denied your request. The Plan says that the request for continued stay in a skilled nursing level of care exceeds your medical needs.

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 services. Our reviewer says that daily skilled services are not necessary. Our physician reviewer found that your condition does not meet Medicare criteria for continued SNF services. 

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 services have not been met. Therefore, we decided that the Plan does not have to pre-approve continued skilled nursing facility (SNF) services.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
You asked the Plan to pre-approve a PET scan. You say that this is medically necessary. The Plan denied your request. The Plan says this is not covered for the enrollee's condition.
The Plan follows Medicare rules. Medicare rules say that Medicare covers Positron Emission Tomography (PET) scans for the differential diagnosis of fronto-temporal dementia (FTD) and Alzheimer's disease (AD) under specific requirements. 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 PET scan. Our reviewer says that the requirements for coverage have not been met. Our physician reviewer found the records provided indicate that the enrollee's working diagnoses are mild dementia, anxiety, and Alzheimer's Disease. As the member is not suspected of having fronto-temporal dementia, the requested PET scan is not medically necessary. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of a PET scan have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain (78608).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for the acute inpatient hospital care provided on May 10, 2021,
to May 12, 2021.
You asked the Plan to pay for acute inpatient hospital care. You say that medical records support that an
inpatient hospital stay was medically necessary. The Plan denied your request. The Plan says these services
could have been treated at an observation level.
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 due to the stability of the patient and only plans for biopsy and monitoring
on steroids, the expected hospital services were not expected to cross two midnights, and observation status
would have been appropriate.
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 on May 10, 2021, to May 12, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the blood smear interpretation rendered on May 11, 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 payment for code 85060 is made only to hospital
inpatients.
We looked at the file and Medicare rules. The file shows that billed procedure code 85060 (blood smear
interpretation) was not performed for a beneficiary under hospital inpatient status. Therefore, we decided that
the Plan does not have to pay for the blood smear interpretation rendered on May 11, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve admission to a skilled nursing facility (SNF).
You asked the Plan to pre-approve SNF care. You say that you need SNF care. The Plan denied your request. The Plan says rules for SNF care have 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 you do not have documented skilled nursing needs. Furthermore, you do not have documented skilled therapy needs. Daily skilled services are not required to establish a maintenance program or to prevent deterioration of your condition. Your care needs are custodial and, as a practical matter, can be provided at a lower level of care. 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 admission to a skilled nursing facility (SNF).
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the office visit (92014) with an
ophthalmologist provided on May 24, 2021.
You asked the Plan to waive the copayment for the office visit. You say that you thought this would be covered
in full because you have the extra vision coverage. The Plan denied your request. The Plan says this was an
office visit with an ophthalmologist in order to receive a medical eye exam. Therefore, the cost-sharing for
medical vision care applies.
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 a $45
copayment for each Medicare-covered visit with a specialist.
You have been asked to pay a $45 copayment for the office visit. The office visit was provided by an
ophthalmologist, which is a type of specialist. 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 the office
visit (92014) with an ophthalmologist provided on May 24, 2021.
Appeal type: Transportation
Decision: Unfavorable

We decided that the Plan does not have to pay for the ambulance service, advanced life support, non-emergency transport, level 1 (A0426), and ground mileage (A0425) provided on April 27, 2021.
You asked the Plan to pay for the transportation services. You say that the claim has been incorrectly denied. You say that you thought you would be responsible for a $290 copayment. You say that you believe you have the right to choose your care provider. The Plan denied your request. The Plan says you signed an advanced beneficiary notice (ABN) acknowledging that the services would not be covered.
The Plan must follow Medicare rules. Medicare rules say that coverage is not available for transport from a hospital capable of treating the patient because the patient and/or the patient's family prefer a specific hospital or physician. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the ambulance services have not been met. Specifically, the record indicates that the ambulance transfer was made due to preference. The record indicates that medically necessary care was available at the sending facility. This means that the transportation services at issue are not covered benefits of Medicare or the Plan. Therefore, we decided that the Plan does not have to pay for the ambulance service, advanced life support, non-emergency transport, level 1 (A0426), and ground mileage (A0425) provided on April 27, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient care provided from February 26, 2021, to March 8, 2021, and billed with diagnosis related group (DRG) 371.
You asked the Plan to pay for inpatient care. You say that this was billed correctly. The Plan denied your request. The Plan says the billed DRG is not supported.
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 371, major gastrointestinal disorders and peritoneal infections with major complications or comorbidities. 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 inpatient care. Our reviewer says that the billed DRG and diagnoses are not supported. Our physician reviewer found the review indicates that the enrollee presented with an inability to tolerate eating and weight loss. Her body mass index on presentation was 21.63 She was evaluated and admitted and seen by nutritional services. She tolerated an oral diet with supplementation with Ensure. The review has determined that DRG 371 was not supported in the medical records. 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 from February 26, 2021, to March 8, 2021, and billed with diagnosis related group (DRG) 371.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
You asked the Plan to pre-approve the LTACH services. You say that the services are necessary. The Plan denied your request. The Plan says based on the documentation provided, coverage criteria has not been met.
The Plan must follow Medicare rules. The rules say that LTACH services are covered if they are medically necessary, reasonable, and appropriate for the diagnosis and condition of the enrollee. We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve the LTACH services. Our reviewer says that the requested LTACH care is not considered medically reasonable and necessary in this case. Our physician reviewer found the medical record does not indicate that the enrollee requires services that she is not currently receiving but that would be available at the LTACH facility. The elements of the coverage rules are not satisfied. The requested service cannot be recommended.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the LTACH services have not been met. Therefore, we decided that the Plan does not have to pre-approve long term acute care hospital (LTACH) services.
Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pay for the fixed bridge (denture) provided for teeth #s 13-15 on
March 26, 2021.
You asked the Plan to pay for the fixed bridge. You say that while you admit that you did not check to see
whether a bridge would be covered, you felt that since it involved crowns, at least those would be paid. The
Plan denied your request. The Plan says fixed bridgework is not covered by your dental plan.
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds
Medicare coverage. For that reason, the Plan's coverage rules apply in this case.
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not
among those covered under this benefit. Therefore, we decided that the Plan does not have to pay for the fixed
bridge (denture) provided for teeth #s 13-15 on March 26, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for surgical services (CPT 20930, 20936, 22854) provided to the enrollee on June 15, 2020.

You asked the Plan to pay for the services. You say that this should be paid for. The Plan denied your request. The Plan says 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 20930:

 Allograft, morselized, or placement of osteopromotive material, for spine surgery only (List separately in addition to code for primary procedure)

CPT 20936:
 Autograft for spine surgery only (includes harvesting the graft); local (eg, ribs, spinous process, or laminar fragments) obtained from same incision (List separately in addition to code for primary procedure) CPT 22854: 

Insertion of intervertebral biomechanical device(s) (eg, synthetic cage, mesh) with integral anterior instrumentation for device anchoring (eg, screws, flanges), when performed, to vertebral corpectomy(ies) (vertebral body resection, partial or complete) defect, in conjunction with interbody arthrodesis, each contiguous defect (List separately in addition to code for primary procedure) 

We asked our coder to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pay for the services. Our reviewer says that the services at issue in this case were not supported by the medical records. Our reviewer found the operative report does not include documentation that an intervertebral biomechanical device (CPT 2284) was inserted. For CPT 20930 and CPT 20936, per the CMS Physician Relative Value File, the codes have an indicator of "B." These codes are inclusive to another procedure and would not be unbundled. 

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 (CPT 20930, 20936, 22854) provided to the enrollee on June 15, 2020.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for hereditary cardiovascular genetic testing provided on February 1, 2021.

You asked the Plan to pay for genetic testing. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this testing is correct, because this testing is non-covered screening.

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 test at issue in this appeal, genetic testing, was requested for screening purposes. Medicare does not cover this test for screening purposes. Therefore, we decided that the Plan does not have to pay for hereditary cardiovascular genetic testing provided on February 1, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pay for injections (64415) provided May 13, 2021.
You asked the Plan to pay for the injections. You say that the services were medically necessary. The Plan denied your request. The Plan says the documentation does not support the claim 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 code 64415 is not supported in the medical record. Specifically, the code billed is missing a required anatomical modifier. Based on this information, we decided that Medicare rules for coverage of the injections have not been met. Therefore, we decided that the Plan does not have to pay for injections (64415) provided May 13, 2021.