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

 We decided that the Plan does not have to waive the deductible for an inpatient hospital stay provided by a participating provider on September 18, 2021, to September 20, 2021.  You asked the Plan to waive the deductible for an inpatient hospital stay. You say that this was an emergency, and you did not stay overnight. The Plan denied your request. The Plan says the correct deductible has been applied.  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 $300 deductible for inpatient hospital care/inpatient hospital care.   You have been asked to pay a $300 deductible for an inpatient hospital stay. The correct copayment has been applied to the inpatient care that was provided. An inpatient hospital stay falls within the inpatient hospital care/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 deductible for an inpatient hospital stay provided by a participating provider on September 18, 2021, to September 20, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pay for an x-ray (74018) provided on September 22, 2021.
You asked the Plan to pay for an x-ray. You say that the enrollee had multiple exams. The Plan denied your
request. The Plan says this is 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 code 70418
is a column II code to column I code 70419. 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 x-ray (74018) provided on September 22, 2021.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network (OON) provider.  You asked the Plan to pre-approve physical therapy services. You say that this care to be provided by an OON provider is medically necessary. The Plan denied your request. The Plan says there are multiple in-network providers available to treat the enrollee's condition.  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 pre-approve care from out-of-network providers only in cases involving emergencies, out of area urgent care and care that cannot be provided by network providers.  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. We found no exception that would require the Plan to pre-approve these items/services. Therefore, we decided that the Plan does not have to pre-approve physical therapy services to be provided by an out-of-network (OON) provider.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the excessive skin excision (15832), the excessive skin and tissue excision (15839) and mastopexy (19316).  You asked the Plan to pre-approve the excessive skin excision (15832), the excessive skin and tissue excision (15839) and mastopexy (19316). The Plan denied your request. The Plan says the request is considered cosmetic and not covered.  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 excessive skin excision (15832), the excessive skin and tissue excision (15839) and mastopexy (19316). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that the enrollee seeks improvement in body appearance and the provider has provided cosmetic surgery price quotes. Our reviewer says that the requested service appears cosmetic in nature and 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 excessive skin excision (15832), the excessive skin and tissue excision (15839) and mastopexy (19316) have not been met. Therefore, we decided that the Plan does not have to pre-approve the excessive skin excision (15832), the excessive skin and tissue excision (15839) and mastopexy (19316).
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve additional transforaminal epidural injections (64484).  You asked the Plan to pre-approve additional transforaminal epidural injections. You say that you are in a lot of pain and having diminished mobility. The Plan denied your request. The Plan says rules for coverage for the requested services have not been met.  The Plan must follow Medicare rules. Medicare rules say that no more than two transforaminal injections may be performed at a single setting.  We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of additional transforaminal epidural injections have not been met. Specifically, the Plan has granted coverage for two transforaminal injections at a single level bilaterally. There is no provision in the rules for more than two transforaminal injections at a single setting. Therefore, we decided that the Plan does not have to pre-approve additional transforaminal epidural injections (64484).
Appeal type: Practitioner Services
Decision: Unfavorable

 We decided that the Plan does not have to pay for the initial hospital care (99223) provided on April 22, 2021.  You asked the Plan to pay for the initial hospital care. You say that you would like reconsideration based on the records submitted. The Plan denied your request. The Plan says the documentation submitted does not support the service 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 99223 is initial hospital care, per day, for the evaluation and management of a patient, which requires these 3 key components: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity. Counseling and/or coordination of care with other physicians, other qualified health care professionals, or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the problem(s) requiring admission are of high severity. Typically, 70 minutes are spent at the bedside and on the patient's hospital floor or unit.   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 initial hospital care. Our reviewer says that CPT code 99223 does not meet criteria for billing or reimbursement consideration. Our reviewer found the documentation does not include an evaluation and management service performed on April 22, 2021, and therefore cannot be confirmed as performed.  Also, documentation includes evaluation and management services provided before date of service billed, but no discharge documentation to support that an initial evaluation and management service would be appropriate.  In this case, no documentation was found to support evaluation and management services were performed on April 22, 2021, and also, an initial evaluation and management code would be inappropriate.  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 initial hospital care have not been met. Therefore, we decided that the Plan does not have to pay for the initial hospital care (99223) provided on April 22, 2021.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve IRF admission and services.  You asked the Plan to pre-approve IRF care. You say that the requested services are a medical necessity for you. The Plan denied your request. The Plan says rules for IRF care have not been met.  The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found that you are medically stable. With comorbid conditions being stable, you do not need physical medicine and rehabilitation physician supervision 3 times per week (at a minimum) for the ongoing management of any active or acute exacerbations of chronic medical conditions. No acute or complex rehab nursing needs are noted in the record. At the current level of function and decreased endurance, you do not need intensive therapies, consisting of at least 3 hours of therapy per day at least 5 days per week with multidisciplinary approach to daily therapy. Your rehab needs can be met at a lower intensity 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 IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an x-ray examination (72040) provided on July 14, 2021.  You asked the Plan to pay for x-ray 72040. You say that you are appealing with supporting records. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the records do not support the use of code 72040 and code 72020 is more appropriate.  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 72040 is radiological examination, spine, cervical; 2 or 3 views.    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 x-ray 72040. Our reviewer says that this code does not meet the criteria for payment. Our reviewer found the documentation states x-rays of the cervical spine were taken showing straightening of lordosis and spasms on right. The documentation does not support 2 or 3 views.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of x-ray 72040 have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray examination (72040) provided on July 14, 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 LTACH care is medically necessary for the enrollee's condition. The Plan denied your request. The Plan says rules for LTACH care have 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 that the enrollee was admitted with acute respiratory failure in the setting of multiple chronic medical conditions. The record indicates that the enrollee remains ventilator dependent and is unable to participate in physical therapy at this time. The record indicates that the enrollee requires ongoing acute care service and may require long term ventilator care. The enrollee continues to receive acute care services, and these have not been denied. The medical record does not indicate that the enrollee requires services that he 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: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve the insertion of stabilization device (22867).  You asked the Plan to pre-approve the insertion of stabilization device (22867). You say that the procedure should be approved. The Plan denied your request. The Plan says the stabilization device is 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 the insertion of stabilization device (22867). Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found that interlaminar spacer devices are experimental. More research is needed to show safety and efficacy.  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 insertion of stabilization device (22867) have not been met. Therefore, we decided that the Plan does not have to pre-approve the insertion of stabilization device (22867).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a Vertiflex Superion device.

You asked the Plan to pre-approve a Vertiflex Superion device. You say that the services are necessary. The Plan denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria have not been met.

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 a Vertiflex Superion device. Our reviewer says that the requested items/services are not considered medically reasonable and necessary in this case. Our physician reviewer found the Vertiflex device is experimental. More research is needed to show safety and efficacy.

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 Vertiflex Superion device have not been met. Therefore, we decided that the Plan does not have to pre-approve a Vertiflex Superion device.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.  You asked the Plan to pre-approve IRF care. You say that the 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 IRF admission is covered only when it is medically reasonable and necessary as described in the Medicare rules section.  We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our physician reviewer found the complexity of your nursing, medical and rehabilitation needs does not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care.   You do not require treatment by multiple therapies, including either physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While you have a need for physical and/or occupational therapy, there is no documentation of a need for an intensive rehabilitation program. There is not a reasonable expectation that you will be able to fully participate in and benefit from the intensive rehabilitation therapy program provided in an IRF.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for an x-ray examination (71046) provided on September 18, 2021.  You asked the Plan to pay for x-ray 71046. You say that this claim denied as a duplicate in error. The Plan denied your request. The Plan says the denial of payment for this service is correct, because the Plan already paid for 1 unit of 71046 and the record does not support a second unit.  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 71046 is radiologic examination, chest, 2 views.   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 x-ray 71046. Our reviewer says that this code does not meet the criteria for payment. Our reviewer found the Plan paid 1 unit of 71046 however this code was listed twice.  We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of x-ray 71046 have not been met. Therefore, we decided that the Plan does not have to pay for an x-ray examination (71046) provided on September 18, 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 that the enrollee continues to receive acute care services. 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.  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: 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 clinical records provided support the need for LTACH care. The Plan denied your request. The Plan says the guidelines for coverage of LTACH care have not been met. The Plan says that the care needed can be provided in the current inpatient hospital.

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 was admitted with altered mental status and seizures due to temporal intraparenchymal hemorrhage. The record indicates that the enrollee continues to have pulmonary edema ad pleural effusions, remains unresponsive, is receiving dialysis, and ventilator dependent. The record indicates that the enrollee requires ongoing acute care services. The enrollee continues to receive acute care services, and these have not been denied. 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.

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: Practitioner Services
Decision: Unfavorable

We decided the Plan does not have to pay for moderate sedation services (99153).
You asked the Plan to pay for moderate sedation services (99153). You say that this claim should be paid. The
Plan denied your request. The Plan says Medicare billing criteria were not met. We overturned the Plans
denial for insufficient claim information in the case file. The Plan requested a reopen and provided additional
claim information. The Plan provided documentation that code 99153 was previously paid by the Plan.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must
report services correctly. Providers must report services with the appropriate codes. In this case the Plan has
submitted documentation to show this code was previously paid for the same date of service. Medicare billing
criteria are not met. There is no additional medical records documentation supporting additional services were
provided. Therefore, we decided that the Plan does not have to pay for moderate sedation services (99153 x7)
provided on February 9, 2021.