Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on June 4, 2021.  

You asked the Plan to waive the copayment for these services. You say that you disagree with the charges. The Plan denied your request. The Plan says the copayment was applied correctly.  

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 $295 copayment for all other outpatient services not provided in an ambulatory surgical center, not including surgical procedures during a colorectal screening.   

Review of the file shows that you received outpatient surgical services (arthrocentesis) on June 4, 2021. Per the contract with the Plan, there is a $295 copayment for all other outpatient services not provided in an ambulatory surgical center, not including surgical procedures during a colorectal screening. This cost sharing is a contractual obligation you agreed to pay when you enrolled in the Plan. However, the Medicare allowed amount for these services was $274.58. Given that the allowed amount was less than the $295 copayment, you have been asked to pay $274.58 for these services.  

Therefore, we decided that the Plan does not have to waive the copayment for the outpatient surgical services rendered on June 4, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an abdominal ultrasound (76705) provided on August 16, 2021.  

You asked the Plan to pay for ultrasound 76705. You say that you are appealing with records to support this level of service. The Plan denied your request. The Plan says the denial of payment for this service is correct, because code 76705 has a procedure-to-procedure (PTP) edit of 1 with code 93976 so is not separately payable without an appropriate modifier.  

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 ultrasound 76705 is a column II code to column I code 93976. 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 an abdominal ultrasound (76705) provided on August 16, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for laboratory services provided on April 20, 2021, June 21, 2021, and September 7, 2021.  You asked the Plan to waive the copayment for the laboratory services. You say that the services should be covered as they were performed in a freestanding location. The Plan denied your request. The Plan says the cost-sharing applied correctly based on the services provided.  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 $40 copayment for Outpatient diagnostic tests and therapeutic services and supplies.    You have been asked to pay a $40 copayment for three separate laboratory service visits for a total cost-sharing of $120. The record indicates that these services were performed in an outpatient setting. Laboratory services fall within the Outpatient diagnostic tests and therapeutic services and supplies 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 laboratory services provided on April 20, 2021, June 21, 2021, and September 7, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility services.
You asked the Plan to pre-approve skilled nursing facility services. You say that skilled nursing facility
services were medically necessary at the time of the appeal. The Plan denied your request. The Plan says
Medicare coverage criteria were not met. Maximus administratively overturned the Plans denial for
information regarding notice lacking in the file. The Plan requested a reopen and provided the required
documentation.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for skilled nursing
facility services. The medical records show you were admitted to the hospital on February 2, 2021 with severe
pain in the hip and lower extremities, with difficulty ambulating. On February 16, 2021 you were admitted to a
skilled nursing facility. On February 22, 2021, you required substantial/maximal assistance for lying to sitting
on side of bed, sit to stand, and bed to chair transfer. The discharge plan noted a likely need for caregiver
assistance in next setting for bathing, dressing, toileting, mobility, and medication management. On February
26, 2021 increased lethargic behavior is documented. As of this date there were no documented skilled nursing
services. The documentation does not support that it was medically reasonable and necessary to receive skilled
services on a daily basis in a skilled nursing facility setting. Medicare coverage criteria for skilled nursing
facility services were no longer met.
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that
Medicare rules for coverage of skilled nursing facility services have not been met. Therefore, we decided that
the Plan does not have to pre-approve skilled nursing facility services
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the chiropractic services rendered on June 30, 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 procedure code 98942 is not supported.

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 98942 is chiropractic manipulative treatment (CMT); spinal, 5 regions. 

We find that CPT code 98942 is not supported in the medical record. Specifically, the records do not document that chiropractic manipulative treatment was performed on 5 spinal regions. 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 chiropractic services rendered on June 30, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.  

You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied your request. The Plan says the services are not medically necessary.  

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 these services. Our reviewer says that the services are not medically necessary. Our physician reviewer found the use of the Vertiflex Superion spacer is not supported in peer-reviewed literature over the gold standard of lumbar laminectomy. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request as an exception to guidelines. Therefore, the request for Vertiflex Superion interspinous spacer device at L3-L4 and L4-L5 is not medically reasonable or necessary.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion spacer.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital care provided February 25, 2020 to March 
6, 2020.

You asked the Plan to pay for the inpatient hospital care. You say that DRG 481 was correctly billed. The Plan 
denied your request. The Plan says DRG 482 more accurately details the services at issue.
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 481. 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 inpatient hospital care. Our reviewer says that DRG 481 is not supported by 
the provided records. Our physician reviewer found the documentation supported an admission for a displaced 
intertrochanteric fracture of right femur, initial encounter for closed fracture. The records show a normal sinus 
rhythm. While the provider documentation indicated a history of chronic atrial fibrillation, this was not 
substantiated in the 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 hospital care provided February 25, 2020 to March 6, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the various medical services provided on May 13, 2019, to August 10, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the medical services. You say that you were not aware this provider was OON. The Plan denied your request. The Plan says prior authorization was not obtained for these services rendered by an OON 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 the various medical services provided on May 13, 2019, to August 10, 2021, by an out-of-network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the Volara system (CPT code E1399), for the enrollee.  

You asked the Plan to pre-approve the system. You say that the system is necessary. The Plan denied your request. The Plan says there is insufficient reliable evidence in the form of high-quality peer-reviewed medical literature to establish the safety and efficacy or effects on health care outcomes of the Volara system. 

 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 system. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Volara system is not medically necessary. This patient has severe chronic obstructive pulmonary disease (COPD), with difficulty raising secretions. There is no bronchiectasis on chest computed tomography (CT) scan. The Volara system combines airway oscillation, positive airway pressure for "lung expansion," and nebulization of medications. There is insufficient evidence that this device is effective in the treatment of lung disease, and it is therefore considered investigational. The denial is upheld. 

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 system have not been met. Therefore, we decided that the Plan does not have to pre-approve the Volara system (CPT code E1399), for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for  a semi-electric hospital bed with foam mattress provided on June 30, 2021. 

 You asked the Plan to pay for  semi-electric hospital bed with foam mattress. You say that the enrollee met medical criteria for this. The Plan denied your request. The Plan says the denial of payment for these items is correct, because the enrollee did not meet Medicare criteria for these items.  

The plan follows Medicare rules. Medicare rules state that a semi-electric hospital bed and foam mattress may be covered under certain circumstances. 

 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 semi-electric hospital bed with foam mattress. Our reviewer says that these items did not meet the Medicare criteria for coverage. Our physician reviewer found the enrollee is not bed-confined and does not require positioning of the body in ways not feasible with a fixed-height hospital bed or even possibly a regular bed, according to the documentation submitted. There was insufficient support made for a specialized semi-electric hospital bed with foam mattress when alternatives were not shown to be contraindicated or not appropriate to treat the enrollee's condition.
 
 We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of semi-electric hospital bed with foam mattress have not been met. Therefore, we decided that the Plan does not have to pay for  a semi-electric hospital bed with foam mattress provided on June 30, 2021.
Appeal type: SNF
Decision: Unfavorable

We decided that the Plan does not have to pre-approve skilled nursing facility (SNF) services.

You asked the Plan to pre-approve SNF services. You say that the enrollee has no right-side mobility and has suffered multiple falls over the last 3 months. You say that he can no longer live at home as he is not getting the correct treatment. The Plan denied your request. The Plan says based on Medicare guidelines, the SNF services you and/or your provider are requesting do not meet the requirements for approval.

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 medically necessary. Our physician reviewer found that from a nursing perspective, the enrollee received oral medications. The enrollee had stable vital signs. His lungs were clear. Regarding rehabilitation services, the enrollee received physical therapy. The enrollee was independent with bed mobility and transfers, and he could walk 1 foot with moderate assist. 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. As a practical matter, the enrollee does not meet severity of illness or intensity of service criteria for an inpatient basis in a skilled nursing facility setting. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of SNF services have not been met. Therefore, we decided that the Plan does not have to pre-approve SNF services.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for anesthesia for a patient of extreme age (99100) provided on April 23, 2021.

You asked the Plan to pay for the anesthesia for a patient of extreme age. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99100 has a status indicator of B.

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 99100 is anesthesia for patient of extreme age, younger than 1 year and older than 70 (List separately in addition to code for primary anesthesia procedure). 

We find that CPT code 99100 is not supported in the record. Specifically, CPT code 99100 has a status indicator of B. This means that the payment for CPT code 99100 is always bundled into the payment for another service or procedure. Based on this information, we decided that Medicare rules for coverage of the anesthesia for a patient of extreme age have not been met. Therefore, we decided that the Plan does not have to pay for anesthesia for a patient of extreme age (99100) provided on April 23, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) (CPT code 22612).  You asked the Plan to pre-approve the service. You say that the service is necessary. The Plan denied your request. The Plan says this is unproven and not medically necessary due to insufficient evidence of efficacy.  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 service. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the requested arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) (CPT 22612) (Stabilink MIS Interlaminar Spinal Fixation System), in this case, is not medically reasonable or necessary.   Current evidence based medical guideline and peer reviewed literature do not fully support the spinal fusion device procedures. There is a lack of large volume, long-term peer-reviewed outcome studies to support the use of this device/spinal fixation system for this enrollee's medical condition as discussed above. There is no compelling rationale presented or extenuating circumstances noted to support the medical necessity of this request/device procedure(s) as an exception. Therefore, the request for arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) (CPT 22612) (Stabilink MIS Interlaminar Spinal Fixation System) is not medically reasonable or necessary.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. Therefore, we decided that the Plan does not have to pre-approve the arthrodesis, posterior or posterolateral technique, single level; lumbar (with lateral transverse technique, when performed) (CPT code 22612).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for inpatient hospital care provided from July 15, 2021, to July 20, 2021.  

You asked the Plan to waive the copayment for inpatient hospital care. You say that you were supposed to receive an electrocardiogram on Friday but did not receive it until Monday. The Plan denied your request. The Plan says the claims were processed correctly and you are being charged the correct 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 a $390 copayment for days 1-5 for inpatient hospital care.   

You received inpatient hospital care from July 15, 2021, to July 20, 2021. Therefore, you are responsible to pay a $390 copayment for days 1-5 (July 15, 2021, to July 19, 2021). However, you are being asked to pay $1,560 which is less than the total copayment amount.   

You have been asked to pay $1,560 for inpatient hospital care. Inpatient hospital care falls 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 care provided from July 15, 2021, to July 20, 2021.
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (99053) provided on May 18, 2021.  

You asked the Plan to pay for the services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says CPT code 99053 has a status indicator of B and payment is always 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.  

We find that CPT code 99053 is not supported in the record. Specifically, CPT code 99053 has a status indicator of B. This means that payment for CPT code 99052 is always bundled into the payment for another service or procedure. Based on this information, we decided that Medicare rules for coverage of the services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service have not been met. 

Therefore, we decided that the Plan does not have to pay for the services provided between 10:00 PM and 8:00 AM at 24-hour facility, in addition to basic service (99053) provided on May 18, 2021.