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

We decided that the Plan does not have to pay for an inpatient admission provided from March 13, 2021, through March 18, 2021.
You asked the Plan to pay for an inpatient admission. The Plan denied your request. The Plan says with the information we have, we cannot determine if a physician's order was given, how the member came to you, the referring provider, and/or whether the services are necessary. All providers are required to furnish necessary information to the health Plan when requested.
The Plan follows Medicare rules. Medicare rules say that the provider must furnish to the intermediary or carrier sufficient information to determine whether payment is due and the amount of payment.
We looked at the file and Medicare rules. The file shows that you did not submit sufficient medical documents to justify payment of the claim. Therefore, we decided that the Plan does not have to pay for an inpatient admission provided from March 13, 2021, through March 18, 2021.
Appeal type: Lab
Decision: Unfavorable

 We decided that the Plan does not have to pay for the laboratory services provided on September 24, 2020.  You asked the Plan to pay for the laboratory services. 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.  The Plan follows Medicare rules. The rules explicitly say that screening tests, with the exception of the few tests listed in the Medicare rules section, are not covered.  The test at issue in this appeal was requested solely for screening purposes. Medicare does not cover this test solely for screening purposes. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on September 24, 2020.
Appeal type: Practitioner Services
Decision: Unfavorable

We decided that the Plan does not have to pay for the medical services provided from January 29, 2021 to March 5, 2021.

You asked the Plan to pay for the medical services. 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.

The Plan must follow Medicare rules. Medicare rules say that for Medicare to consider coverage and payment for any item or service, the information submitted by the supplier or provider must confirm that Medicare coverage criteria have been met.

We looked at the file and Medicare rules. In this case, there were no medical records provided for us to be able to verify if the services provided were billed correctly per Medicare guidelines. Therefore, we decided that the Plan does not have to pay for the medical services provided from January 29, 2021 to March 5, 2021.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services provided on May 10, 2021.

You asked the Plan to pay for the laboratory services. 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.

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services provided on May 10, 2021.
Appeal type: Transportation
Decision: Unfavorable

 We decided that the Plan does not have to waive the copayment for the ambulance transportation services (A0425, A0429) provided on July 4, 2021.  You asked the Plan to waive the copayment for the ambulance transportation. You say that you do not remember being transported and feel you do not owe this cost-sharing amount. The Plan denied your request. The Plan says this claim was processed correctly, and your cost sharing was applied 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 $100 copayment for ambulance services.    You have been asked to pay a $100 copayment for the ambulance transportation. Medical records were provided to support these services. 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 (A0425, A0429) provided on July 4, 2021.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 We decided that the Plan does not have to pay for the miscellaneous supplies (A9900) provided on May 31, 2021.  You asked the Plan to pay for the miscellaneous supplies. You say that you would like this claim reprocessed in consideration of coding guidelines. The Plan denied your request. The Plan says no payment can be made for these services under the Physician Fee Schedule.  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 A9900 is miscellaneous dme supply, accessory, and/or service component of another hcpcs code.   We find that CPT code A9900 is not supported in the medical record. Specifically, this service has a Status Code of X which indicates a Statutory Exclusion. In this case, no payment can be made under the Physician Fee Schedule. Based on this information, we decided that Medicare rules for coverage of the miscellaneous supplies have not been met. Therefore, we decided that the Plan does not have to pay for the miscellaneous supplies (A9900) provided on May 31, 2021.
Appeal type: Practitioner Services
Decision: Favorable

We decided that the Plan has to pay for the anesthesia services coded as 00920 provided on April 22, 2021.

You asked the Plan to pay for the anesthesia services. You say that you would like these claims reprocessed for medical necessity. The Plan denied your request. The Plan says that this claim has bundled with a previously paid claim and no separate payment is due.

The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or payment. 

The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their decision to deny your request. In this case, the Plan has indicated this claim is bundled with a previously paid claim. However, this claim was not submitted with the appeal. Without this documentation, we cannot confirm the Plan's argument that the services are included in a previous claim. Therefore, we decided that the Plan has to pay for the anesthesia services coded as 00920 provided on April 22, 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: Testing
Decision: Unfavorable

We decided that the Plan does not have to pay for the sleep study, unattended (95806).

You asked the Plan to pay for the sleep study. You say that you feel this should have been covered. You say
that the results indicated that you have mild sleep apnea. You also say that this was not a frivolous test. The
Plan denied your request. The Plan says the provided documentation does not indicate that the requirements for
approval have been met.

The Plan follows Medicare rules. Medicare rules say that neither in facility polysomnography nor out of center
testing (OCST) testing is a covered service for Medicare beneficiaries for general screening of asymptomatic
populations.

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 sleep study. Our reviewer says that the
sleep study was not medically necessary. Our physician reviewer found the provided documentation indicates
that the enrollee was suspected of possibly having obstructive sleep apnea (OSA) based on low hematocrit
levels. The reviewer found that the enrollee had no contraindications to the use of an out of center sleep testing
(OCST). The reviewer also found that the enrollee had no formal symptoms of OSA by history and denied any
of the cardinal symptoms of OSA upon questioning. Therefore, the reviewer found that the sleep study does not
meet the requirements for 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 sleep study have not been met. Specifically, the file shows that you do not
have formal symptoms of obstructive sleep apnea (OSA) by history and denied any of the cardinal symptoms
of OSA upon questioning. Therefore, we decided that the Plan does not have to pay for the sleep study,
unattended (95806).
Appeal type: DME/ Orthotics
Decision: Unfavorable

We decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on May 21, 2021.
You asked the Plan to pay for pneumatic compression devices. You say that the items at issue were a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for payment have not been met.
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the purpose of prevention of venous thromboembolism is a preventive service. The rules also say that a PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for coverage of the PCD have not been met. Specifically, these items are not a covered benefit of Medicare or the Plan.
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to pay for pneumatic compression devices (E0675, E0673) provided on May 21, 2021
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual (CPT code 88120) provided to the enrollee on November 9, 2020.

You asked the Plan to pay for the service. You say that the service was medically necessary. The Plan denied your request. The Plan says the service is not covered.

The Plan must follow Medicare rules. We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for coverage of the service have not been met. The services are not authorized because code 88120 is not a Medicare benefit for the diagnosis listed on the claim (R86.6 - Abnormal cytological findings in specimens from male genital organs) and is done for screening purposes. Cystoscopy in conjunction with bladder tumor markers is standard practice to evaluate patients with symptoms suggesting bladder cancer and to monitor treated patients for recurrence or progression. Bladder cancer tumor markers performed by any technology immunoassay, molecular or FISH testing, are not covered for screening of all patients with hematuria. Bladder tumor markers are not expected to be performed until other diagnostic studies fail to identify the etiology of the hematuria. Urine cytology is not considered a bladder tumor marker.

Therefore, we decided that the Plan does not have to pay for cytopathology, in situ hybridization (eg, FISH), urinary tract specimen with morphometric analysis, 3-5 molecular probes, each specimen; manual (CPT code 88120) provided to the enrollee on November 9, 2020.
Appeal type: Drugs
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve a tier exception for Prolia.  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 drug is not eligible for a tier exception.  The Plan must follow Medicare rules. Medicare rules say that Part B drugs are not eligible for a Part D tier exception.  We looked at the file and Medicare rules. The requested Prolia is covered by Part B Medicare and not eligible for a Part D tier exception. Therefore, we decided that the Plan does not have to pre-approve a tier exception for Prolia.
Appeal type: Imaging
Decision: Unfavorable

 We decided that the Plan does not have to pay for the computed tomography (CT) scan (70470) provided on July 16, 2021.  You asked the Plan to pay for the CT scan. You say that you would like this claim reprocessed based on the medical documentation provided. The Plan denied your request. The Plan says an appropriate modifier was not billed as required by Medicare rules for this 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, we have confirmed that code 70470 is a column II code to column I code 70496. 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 computed tomography (CT) scan (70470) provided on July 16, 2021.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 We decided that the Plan does not have to pay for ophthalmological services provided on July 16, 2021.  You asked the Plan to pay for ophthalmological services. You say that the exam was medically necessary. The Plan denied your request. The Plan says your Plan only covers in-network provider and this provider is not in your network.  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.  We looked at the file and the Plan's rules. The file shows that the ophthalmological services were not provided by an in-network provider. Based on this information, we decided that the Plan's rules for coverage of ophthalmological services have not been met. Therefore, we decided that the Plan does not have to pay for ophthalmological services provided on July 16, 2021.
Appeal type: Imaging
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain.

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 a brain PET is covered when specific criteria are met. 

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 records show that you do not meet the diagnostic criteria for Alzheimer's dementia (AD) or fronto-temporal dementia (FTD). There is no workup to rule out other neurodegenerative diseases or other causes for your symptoms. The criteria are not met and the PET scan is not reasonable or medically necessary. 

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not have to pre-approve a positron emission tomography (PET) scan of the brain.
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. The Plan denied your request. The Plan says the enrollee is currently unstable for transfer.  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 physician reviewer found that the enrollee was admitted to the acute care hospital with a left hip fracture. There are no complex medical, nursing, or wound care needs. Care at an LTACH will not change the enrollee's short or long-term outcome. Therefore, the requested services are 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 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 that the Plan does not have to pay for the office visits provided on January 25, 2021, to March 8, 2021, by an out-of-network (OON) provider.  You asked the Plan to pay for the office visits. You say that you are appealing these claims. The Plan denied your request. The Plan says no prior authorization was obtained.  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 did not pre-approve the item/service at issue. We found no exception that would require the Plan to pay for these items/services. The records provided for review do not show that the services at issue were urgent or emergent. Therefore, we decided that the Plan does not have to pay for the office visits provided on January 25, 2021, to March 8, 2021, by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the laboratory services (87486, 87581, 87631, and 87798) provided on October 9, 2020.

You asked the Plan to pay for the laboratory services. 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. 

We looked at the file and Medicare rules. In this case, the claim was billed with an incorrect place of service (POS) code per Medicare guidelines. The records show that the specimen was obtained in an office setting. Therefore, we decided that the Plan does not have to pay for the laboratory services (87486, 87581, 87631, and 87798) provided on October 9, 2020.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 We decided that the Plan does not have to pay for the inpatient hospital care provided from September 8, 2020, through September 13, 2020, and billed with a principal diagnosis code A41.9.  You asked the Plan to pay for the inpatient hospital care. You say that the documentation supports the inpatient hospital services as billed. The Plan denied your request. The Plan says the medical documentation does not support the principal diagnosis code as billed.  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 principal diagnosis code, A41.9, defined as sepsis, unspecified organism. 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 the medical documentation does not support the inpatient hospital care as billed. Our physician reviewer found the review indicates that the documentation supported an admission for pneumonia. The enrollee was a then 76-year-old with a history of chronic lymphocytic leukemia who presented to the emergency department on September 8, 2020, with complaints of fever, dry cough, shortness of breath and fatigue. Vital signs were stable and O2 sat was 91% on room air. Treatment included IV fluids and IV antibiotics, there were no clinical or laboratory signs of sepsis. The enrollee remained hemodynamically stable. The review has determined that the documentation did not support the billed principal diagnosis code A41.9 defined as sepsis unspecified organism.   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 the inpatient hospital care provided from September 8, 2020, through September 13, 2020, and billed with a principal diagnosis code A41.9.
Appeal type: Surgery
Decision: Unfavorable

 We decided that the Plan does not have to pre-approve implantation of a StimQ PNS system.  You asked the Plan to pre-approve implantation of a StimQ PNS system. You say that the requested services are a medical necessity for the enrollee. The Plan denied your request. The Plan says rules for coverage have not been met because the requested services are experimental/investigational.  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 implantation of a StimQ PNS system. Our reviewer says that the requested services are not considered medically reasonable and necessary in this case. Our physician reviewer found that there is a lack of high quality randomized controlled trials and long-term efficacy data. The requested device is still considered experimental/investigational.  We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that Medicare rules for coverage of implantation of a StimQ PNS system have not been met. Therefore, we decided that the Plan does not have to pre-approve implantation of a StimQ PNS system.