Persius/hicric huggingface dataset:
Appeal type: Transportation
Decision: Favorable

 We decided that the Plan has to pay for ambulance transport provided to the enrollee on July 13, 2021.  You asked the Plan to pay for this transport. You say that this claim should be paid. The Plan denied your request. The Plan says that Medicare billing criteria were not met.  Medicare pays for ambulance services only when an emergency exists or when other means of transport would endanger the patient's health. The Plan follows the same rules.   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 this transport. Our reviewer says that Medicare coverage criteria are not met. Our physician reviewer found in this case; the record indicates that the enrollee was transported from the street to an acute care location. The record indicates that the enrollee was transported via stretcher.  A prudent layperson would believe that without immediate medical attention there would be serious jeopardy to his or her health. The elements of the coverage criteria are satisfied.  The requested service is 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 this transport have been met. Therefore, we decided that the Plan has to pay for ambulance transport provided to the enrollee on July 13, 2021.   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 waive the deductible for an ECG provided on September 3, 2021.  You asked the Plan to waive the deductible for an ECG. You say that you disagree with the additional charges and should only owe a $25 specialist copayment. 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. Your contract with the Plan says that there is a $500 deductible which applies to outpatient diagnostic tests, therapeutic services and supplies.   The record shows that you received an ECG on September 3, 2021. The record shows that you only paid $43.33 toward the $500 deductible prior to receiving the services. Therefore, you are responsible to pay the allowed amount of $8.04.    The item or service you asked the Plan to waive the deductible for falls within the benefit category outpatient diagnostic tests, therapeutic services and supplies. The Plan has followed Medicare rules by clearly disclosing in the contract that there is a $500 deductible which applies to outpatient diagnostic tests, therapeutic services and supplies. This cost sharing is a contractual obligation that had not been met at the time an ECG was received on September 3, 2021. Therefore, we decided that the Plan does not have to waive the deductible for an ECG provided on September 3, 2021.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to waive the copayments for posterior tibial neurostimulation provided from July 26, 2021, to August 23, 2021.

You asked the Plan to waive the copayments for posterior tibial neurostimulation. You say that you received the services in a physician's office and disagree with the charges. 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 $275 copayment for outpatient surgery and other medical services provided at hospital outpatient facilities.

The record shows that you received posterior tibial neurostimulation at an outpatient hospital facility from July 26, 2021, to August 23, 2021, for a total of 5 visits. Posterior tibial neurostimulation is considered an outpatient surgical procedure. Therefore, you are responsible to pay the allowed amount of $250.34, which is less than the $275 copayment, per each service. The total amount you owe is: $250.34 (copayment) x 5 (services) = $1,251.70. 

You have been asked to pay the total copayment amount of $1,251.70 for posterior tibial neurostimulation. Posterior tibial neurostimulation falls within the outpatient surgery and other medical services provided at hospital outpatient facilities and ambulatory surgical centers 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 copayments for posterior tibial neurostimulation provided from July 26, 2021, to August 23, 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 for the enrollee.
You asked the Plan to pre-approve IRF care. You say that these services are medically necessary. The Plan
denied your request. The Plan says that the enrollee's ongoing skilled therapy and nursing needs can be
provided at a lower level of care.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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. The
complexity of the patient's nursing, medical and rehabilitation needs does not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. The patient was admitted for medical and surgical
treatment of epidural abscess and osteomyelitis/discitis of thoracic spine. The enrollee's medical conditions are
stable. There are no medical needs requiring inpatient admission. There are no complex nursing or
rehabilitation needs. The patient does not require treatment by multiple therapies, including either physical
therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical record
documents a need for physical and occupational therapy, it does not document a need for an intensive
rehabilitation program. There is not a reasonable expectation that this patient will be able to fully participate in
and benefit from the intensive rehabilitation therapy program provided in an IRF. Our physician reviewer
found that the enrollee's condition does not meet Medicare criteria for IRF 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 for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for physician services provided to the enrollee on May 19, 2021, and billed under codes 49203, 49202, 15750, and 38747.  You asked the Plan to pay for these services. You say that this claim should be paid. The Plan denied your request. The Plan says Medicare billing criteria are not met.  The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report services with the appropriate codes. 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 these services. Our reviewer says that Medicare billing criteria are not met. Our reviewer says that for code 49203, the Operative report describes a mass was removed from the pancreatic head, including the pancreatic head, distal bile duct, duodenum, gallbladder, and all regional lymph nodes.  Per NCCI Policy Manual - intraabdominal tumors, cysts, or endometriomas or secondary mesenteric, peritoneal, or retroperitoneal tumors are destroyed or removed.  Code 49202 is an incorrect code to report for procedure documented. The documentation also does not include tumor 5 cm diameter or less. For code 15750 the operative report does not include documentation of neurovascular pedicle flap was performed. For code 38747, the provider reported this procedure with modifier 59 appended. The operative report does not describe the guidelines required to append modifier 59, and therefore cannot be verified as a distinct procedure.   Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-evaluation and management (E/M) services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. Modifier 59 should only be used if no other more specific modifier is appropriate.    We looked at this coder'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 pay for physician services provided to the enrollee on May 19, 2021, and billed under codes 49203, 49202, 15750, and 38747.
Appeal type: Drugs
Decision: Unfavorable

We decided that the Plan does not have to pre-approve Ferumoxytol.

You asked the Plan to pre-approve the drug. You say that this is medically necessary. The Plan denied your request. The Plan says there is no information provided as to why the enrollee cannot have one of the formulary choices.

Medicare covers Part B medications when they are reasonable and necessary but allows health plans to implement step therapy criteria. The Plan's contract indicates that it has implemented such criteria for certain Part B medications.

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 drug. Our reviewer says that the requested drug is not medically reasonable or necessary. Our physician reviewer found the record indicates that the enrollee has iron deficiency anemia. The provided records do not indicate that the enrollee has tried and failed the plan's preferred step one alternatives - Ferrlecit, Infed or Venofer. The record does not indicate that the enrollee has a contraindication to, or would have an adverse effect from the plan's preferred step one alternative. The elements of the coverage criteria are not satisfied.

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the drug have not been met. Therefore, we decided that the Plan does not have to pre-approve Ferumoxytol.
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pre-approve acute IRF admission and services.
You asked the Plan to pre-approve IRF care. You say that skilled nursing is not an appropriate safe level of
care at this time. The Plan denied your request. The Plan says the enrollee's care is not complex, and he doesn't
need a team of providers.
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically
reasonable and necessary as described above.
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 presented to the acute hospital with altered mental status from his neurologist's office. He was
treated in the hospital with lactulose for elevated ammonia levels and improved. He is weak and deconditioned.
He is not walking due to weakness, and is at a moderate to maximum assist level for transfers and activities of
daily living. He is reported to be lethargic and disoriented with therapy, but medically stable for discharge. The
complexity of the enrollee's nursing, medical and rehabilitation needs do not require an acute hospital inpatient
stay with an interdisciplinary approach to rehabilitation care. There is no documentation that he requires the
intensive rehabilitation therapy program provided in an IRF. He does require physical and occupational therapy
services, but the enrollee does not require an intensive inpatient rehabilitation therapy program.
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: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve absolute quantification of myocardial blood flow (AQMBF) with positron emission tomography (PET) for the enrollee.  You asked the Plan to pre-approve the services. You say that this is medically necessary. The Plan denied your request. The Plan says there has no been no inconclusive single-photon emission computed tomography (SPECT), and there are no current plans for revascularization.  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 services. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case.   Our physician reviewer found the record indicates that the enrollee has known coronary artery disease and is having increasing fatigue. The record does not indicate that revascularization is planned or that the enrollee has undergone a single-photon emission computed tomography (SPECT) study that demonstrated inconclusive results. The elements of the coverage criteria are not satisfied.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the services have not been met. Therefore, we decided that the Plan does not have to pre-approve absolute quantification of myocardial blood flow (AQMBF) with positron emission tomography (PET) for the enrollee.
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for the replacement of lead wires provided on September 6, 2020.
You asked the Plan to pay for the lead wires. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says a TENS unit has been purchased in the previous 12 months.
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 A4557 is lead wires, (e.g., apnea monitor), per pair. We find that CPT code A4557 is not supported in the medical record. Specifically, the records show that lead wires were provided within the last 12 months. There are insufficient records to show that additional lead wires were medically reasonable and necessary for the enrollee's device. Based on this information, we decided that Medicare rules for coverage of the lead wires have not been met. Therefore, we decided that the Plan does not have to pay for the replacement of lead wires provided on September 6, 2020.
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 the admission. You say that this is medically necessary. The Plan denied your request. The Plan says the services required can be safely received in a different setting, for example, home with home health, in residential care, or home with close follow-up from the 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 the admission. 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 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 the admission 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: Transportation
Decision: Unfavorable

We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0427) provided on June 14, 2021.

You asked the Plan to waive the copayment for the ambulance transportation. You say that the price for this service is too high. The Plan denied your request. The Plan says this service is covered, and your copayment was assessed in accordance with your contract.

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 $225 copayment per day for ambulance services. 

You have been asked to pay a $225 copayment for the ambulance transportation. 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 ambulance transportation services (A0427) provided on June 14, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for the screening mammography, bilateral (two-view study of each breast), including CAD when performed (77067) and screening digital breast tomosynthesis, bilateral provided on November 5, 2020 by an out of network (OON) provider.
You asked the Plan to pay for the screening mammography. You say that reprocess the claim for payment with referring provider's order. The Plan denied your request. The Plan says enrollee's must receive their medical services from an in-network provider with the exception being urgent or emergent services. Non-emergent services with non-contracted providers require prior authorization before services being rendered.
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 has network providers available who can provide 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 screening mammography, bilateral (two-view study of each breast), including CAD when performed (77067) and screening digital breast tomosynthesis, bilateral provided on November 5, 2020 by an out of network (OON) provider.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for a manual wheelchair (E0971, K0005, E0163, E2601) provided August 4, 2021.  You asked the Plan to pay for the manual wheelchair. You say that the item was medically necessary. The Plan denied your request. The Plan says the provided documentation does not support the items billed.  The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there are both a physician order and proof of delivery.   The record does not contain a valid physician order, proof of delivery, or relevant medical records which support medical necessity for the supplies provided in this case. The records do not show a relationship between the enrollee and the physician. There is not a signed physician order for each item. The record shows that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we decided that the Plan does not have to pay for a manual wheelchair (E0971, K0005, E0163, E2601) provided August 4, 2021.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pay for the Retrobulbar injection (67500) provided on May 11, 2021.  You asked the Plan to pay for code 67500. You say that you would like the Plan to reconsider their denial of payment. The Plan denied your request. The Plan says the services are not covered 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, we have confirmed that code 67500 is a column II code to column I code 00140. 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 Retrobulbar injection (67500) provided on May 11, 2021.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the bone density scan of axial bones like hip, pelvis and spine (77080) provided March 18, 2021.  You asked the Plan to pay for the bone density scan. You say that this was originally M89.9 but was corrected to N95.1 on 05/03/2021. N95.1 is on the LCD. Kindly reprocess the claim. The Plan denied your request. The Plan says missing or inappropriate diagnosis billed on claim.  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 77080 is bone density scan of axial bones like hip, pelvis and spine.  We find that CPT code 77080 is not supported in the medical record. Specifically, the diagnosis of the enrollee N95.1 menopausal and female climacteric states billed on the claim with CPT code 77080 does not match the approved diagnosis in NCD 150.3. Therefore, the diagnosis is not covered. Based on this information, we decided that Medicare rules for coverage of the bone density scan have not been met. Therefore, we decided that the Plan does not have to pay for the bone density scan of axial bones like hip, pelvis and spine (77080) provided March 18, 2021.