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

 We decided that the Plan does not have to pay for the services (70450, 70544) provided on September 9, 2021, and September 10, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says these services are bundled.  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. Code 70544 is a column II code to column I code 70553. 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, 70544) provided on September 9, 2021, and September 10, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the drug testing services (G0483) provided on February 9, 2021.  You asked the Plan to pay for the services. The Plan denied your request. The Plan says the services were billed with the incorrect place of service.  The Plan must follow Medicare rules. Medicare rules say that the POS code to be used by the physician or other supplier will be assigned as the same setting in which the beneficiary received the face-to-face service.   We looked at the file and Medicare rules. The documentation shows that the services in question were billed with POS code 81. However, the records indicate that the specimen was collected in an office setting, which would be indicated by POS code 11. This means that the claim was billed with the incorrect POS code. 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 drug testing services (G0483) provided on February 9, 2021.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF 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 SNF criteria. The Plan states the enrollee has completed your intensive course of care at the inpatient rehabilitation facility (IRF) and intermittent therapy can safely be received at a different setting, for example, home with home health or outpatient therapy in residential care.  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 there are no identifiable skilled nursing service needs. There are identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. The enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care.
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 it would be unsafe to discharge the enrollee at his current state of function. The Plan denied your request. The Plan says the enrollee does not require an intensive therapy program with multiple visits from a rehabilitation doctor per week.  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 physician reviewer found that the enrollee was admitted to the acute care hospital for weakness and falls after a recent coronavirus infection. His medical problems are stable. The complexity of his nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation 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 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 psychotherapy (90837) provided on March 1, 2021, by an OON provider  You asked the Plan to pay for psychotherapy. You say that you are appealing with supporting records. The Plan denied your request. The Plan says this claim was denied due to no prior authorization for this date of service. The Plan also says that this provider is a non-participating provider and the Plan did not authorize any services for this provider.  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 psychotherapy (90837) provided on March 1, 2021, by an OON provider
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF 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 SNF criteria. The Plan states the enrollee completed their intensive course of care at the inpatient rehabilitation facility (IRF) and intermittent therapy can safely be received at a different setting, for example, home with home health or outpatient therapy in residential care.  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 there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. The enrollee does not require skilled nursing or therapy services on a daily basis. This enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care.
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 appears to be still somewhat unstable and requires short-term additional acute care services that can safely be administered at the current facility for the time being. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered soon when treatment has completed and the enrollee is more stable.   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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the knee orthosis (CPT code L1852), for the enrollee.  You asked the Plan to pre-approve the knee orthosis. You say that the enrollee is in need of this brace so that they may walk without instability of their right knee. The Plan denied your request. The Plan says your request is not medically necessary because the enrollee does not have objective evidence of instability.  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 knee orthosis. Our physician reviewer found the reviewed documentation indicates that the enrollee has knee pain that may benefit from bracing. There is no clinical evidence of instability in the joint, although a physical exam was performed. The review has determined that the medical records provided do not meet the requirements listed in the LCD for Medicare coverage.  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 knee orthosis have not been met. Therefore, we decided that the Plan does not have to pre-approve the knee orthosis (CPT code L1852), for the enrollee.
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 appears to be a poor candidate for weaning and only requires short-term additional acute care services that can safely be administered at the current facility until a more appropriate lower level of care is arranged.  There are no services at the LTACH that the enrollee requires that are not already available and covered at the current facility. Transfer to a lower level of care may be considered soon when treatment has completed.  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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the tissue exam (88305) provided on May 26, 2021.  You asked the Plan to pay for the tissue exam. You say that you would like reconsideration because this testing was medically necessary. The Plan denied your request. The Plan says procedure code 88305 has a physician Fee Schedule PCTC indicator of 1.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly.   We find that CPT code 88305 is not supported in the record. Specifically, the record indicates that the member was in an outpatient facility on the billed date of service. The record also shows that CPT code 88305 was billed by the facility on the same date of service. Payment for the technical component of this service is included in the payment to the facility and is the responsibility of the facility to any vendor. Based on this information, we decided that Medicare rules for coverage of the tissue exam have not been met. Therefore, we decided that the Plan does not have to pay for the tissue exam (88305) provided on May 26, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the prostate biopsy (G0416) and the laboratory services (88341, 88342, 88344) rendered by the out-of-network (OON) provider on September 21, 2021.  You asked the Plan to pay for these services. You say that you are requesting a reconsideration of the Plan's denial for payment. The Plan denied your request. The Plan says the services were rendered by an out of network provider, without prior authorization.  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 services at issue in this appeal. The Plan did not pre-approve the services at issue. We found no exception that would require the Plan to pay for these services. Therefore, we decided that the Plan does not have to pay for the prostate biopsy (G0416) and the laboratory services (88341, 88342, 88344) rendered by the out-of-network (OON) provider on September 21, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the eye injection (66020) provided on December 27, 2019.  You asked the Plan to pay for the eye injection (66020). You say that the office submitted the claim within the correct time limit. You say that the claim should be reprocessed and paid correctly. The Plan denied your request. The Plan says the claim was filed past the allowed 12-month timeframe.  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 the eye injection (66020) was not received until July 22, 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 eye injection (66020) provided on December 27, 2019.
Appeal type: SNF
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve SNF care.  You asked the Plan to pre-approve SNF care. You say that the stay is medically necessary. The Plan denied your request. The Plan says your records do not show you do not require skilled nursing services or skilled rehabilitation services on a daily basis, and which can only be provided on an inpatient basis in a SNF.  The Plan states your rehabilitation and medical needs can be met with part-time skilled services in a lower level of care, such as home with supervision and home health services. The Plan states home health services will need to be approved by your health plan. The Plan states your rehabilitation needs can safely be received at a different setting, for example, home with home health, in residential care, or home with close follow-up with your doctor.  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 there are no identifiable skilled nursing service needs. There are no identifiable skilled therapy service needs. You do not require skilled nursing or therapy services on a daily basis. You do not meet severity of illness or intensity of service criteria for an inpatient basis in a SNF 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 SNF care.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on June 3, 2021.  You asked the Plan to pay for the surgical pathology services. You say that you would like the plan to reconsider their denial. The Plan denied your request. The Plan says the services are not payable as billed.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate CPT code.      In this case, the CPT Code Manual definition of code 88305 is Level IV - Surgical pathology, gross and microscopic examination Abortion - spontaneous/missed Artery, biopsy Bone marrow, biopsy Bone exostosis Brain/meninges, other than for tumor resection Breast, biopsy, not requiring microscopic evaluation of surgical margins Breast, reduction mammoplasty Bronchus, biopsy Cell block, any source Cervix, biopsy Colon, biopsy Duodenum, biopsy Endocervix, curetting/biopsy Endometrium, curetting/biopsy Esophagus, biopsy Extremity, amputation, traumatic Fallopian tube, biopsy Fallopian tube, ectopic pregnancy Femoral head, fracture Fingers/toes, amputation, non-traumatic Gingiva/oral mucosa, biopsy Heart valve Joint, resection Kidney, biopsy Larynx, biopsy Leiomyoma(s), uterine myomectomy - without uterus Lip, biopsy/wedge resection Lung, transbronchial biopsy Lymph node, biopsy Muscle, biopsy Nasal mucosa, biopsy Nasopharynx/oropharynx, biopsy Nerve, biopsy Odontogenic/dental cyst Omentum, biopsy Ovary with or without tube, non-neoplastic Ovary, biopsy/wedge resection Parathyroid gland Peritoneum, biopsy Pituitary tumor Placenta, other than third trimester Pleura/pericardium - biopsy/tissue Polyp, cervical/endometrial Polyp, colorectal Polyp, stomach/small intestine Prostate, needle biopsy Prostate, TUR Salivary gland, biopsy Sinus, paranasal biopsy Skin, other than cyst/tag/debridement/plastic repair Small intestine, biopsy Soft tissue, other than tumor/mass/lipoma/debridement Spleen Stomach, biopsy Synovium Testis, other than tumor/biopsy/castration Thyroglossal duct/brachial cleft cyst Tongue, biopsy Tonsil, biopsy Trachea, biopsy Ureter, biopsy Urethra, biopsy Urinary bladder, biopsy Uterus, with or without tubes and ovaries, for prolapse Vagina, biopsy Vulva/labia, biopsy.  We find that CPT code 88305 is not supported in the medical record. Specifically, this code has a physician fee schedule professional component/technical component indicator of 1. The documentation shows that the enrollee was an outpatient on this date of service and the facility rendered this service. In addition, another provider rendered this same service code on the same date of service. This means this code is not separately payable. Based on this information, we decided that Medicare rules for coverage of the surgical pathology services have not been met. Therefore, we decided that the Plan does not have to pay for the surgical pathology services coded 88305 provided on June 3, 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 admission to an LTACH is medically necessary. The Plan denied your request. The Plan says the admission to an LTACH is not medically necessary.  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 based on the documentation provided the enrollee only requires short-term additional acute care services that can safely be administered at the current facility. The enrollee does not require services at the LTACH that are not already available at the current facility. There are no services at the LTACH that the enrollee requires that are not already available and covered at the current 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: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.  You asked the Plan to pre-approve the home ventilator. You say that the ventilator is to be used for the treatment of chronic obstructive pulmonary disease (COPD). The Plan denied your request. The Plan says the request for a home mechanical ventilator set in average volume-assured pressure support (AVAPS) mode that could be delivered by bilevel positive airway pressure (BiPAP) is not covered.  The Plan must follow Medicare rules. The rules say that ventilators may be covered when they are medically necessary for patients who have neuromuscular disease, thoracic restrictive diseases, and chronic respiratory failure due to COPD.  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 home ventilator. Our physician reviewer found a home ventilator is not medically necessary. This enrollee has severe COPD. There is no documentation of carbon dioxide (CO2) retention on an arterial blood gas (ABG) obtained while the enrollee is awake and stable as an outpatient. Medicare does not cover a ventilator when used as BiPAP, and the AVAPS mode can be provided via BiPAP at less cost to the enrollee.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the home ventilator have not been met. Therefore, we decided that the Plan does not have to pre-approve the home ventilator (CPT code E0466), for the enrollee.